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    This position is located in the Business Management Service- Clinical Documentation Improvement (CDI) section at the Birmingham VA Medical Center, Birmingham Alabama. Medical Record Technician- Clinical Documentation Improvement Specialists (MRT-CDIS) are responsible for providing expertise and improved overall, quality, education, and completeness and accuracy of medical record documentation.

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    This is an OPEN CONTINUOUS ANNOUNCEMENT and will remain open until June 30, 2021. The initial cut-off date for referral of eligible applications will be 12 April 2021. Eligible applications received after that date will be referred at regular intervals, every Monday, or as additional vacancies occur on an as-needed basis until positions are filled.

    Medical Records Technician (CDIS) major duties include but are not limited to the following:

    • Serve as technical expert in health record content and documentation requirements.
    • Ensure accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
    • Perform reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
    • Accountable for utilizing a variety of collaborative strategies with physicians, mid-level providers and other members of the interdisciplinary team, Medical Care Cost Recovery (MCCR) and Health Information Management Section.
    • Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data.
    • Apply comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medication procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
    • Conducts reviews of both inpatient and outpatient documentation to identify those with potential, documentation improvement opportunities, through periodic evaluation during the patient's stay or visit.
    • Search the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
    • Adhere to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary.
    • Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
    • Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
    • Develop and implement ICD-10 CM/PCS training/education programs for all providers to ensure the CDIS program objectives are met.
    • Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance.

    Work Schedule: Monday - Friday 0730-1600
    Financial Disclosure Report: Not required

    Travel Required

    Not required

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/596997300. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.