Medical Records Technician (Clinical Documentation Improvement Specialist (Outpatient/Inpatient))

Veterans Health Administration • Martinsburg, WV

3d • Onsite

About The Position

This position is a Medical Records Technician (Clinical Documentation Improvement Specialist) in the Health Information Management section at the Martinsburg VA Medical Center. The role reviews patient health records to improve the quality, completeness, and accuracy of clinical documentation for both inpatient and outpatient care. The technician applies knowledge of medical terminology, anatomy and physiology, disease processes, treatments, tests, medications, procedures, health services, and organizational record structure to support accurate code selection and high-quality health data. The role works closely with providers, other clinical staff, and HIM coding personnel through documentation queries, consultation, and education. It also supports training, data quality and compliance efforts, and appropriate reimbursement and resource allocation. The position is not virtual. The work schedule is Monday through Friday, 7:00 a.m. to 3:30 p.m.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Proficiency in written and spoken English.
• Meet the basic qualification requirements through one of the stated pathways: one year of qualifying experience; an applicable associate's degree; completion of an eligible coding training program; or an allowable combination of experience and education.
• Hold an applicable AHIMA or AAPC Apprentice/Associate or Mastery Level certification, or a Clinical Documentation Improvement certification through AHIMA or ACDIS, unless covered by the stated grandfathering provision.
• For the GS-9 grade, meet one of the stated qualification pathways: one year of experience equivalent to the journey grade level of an inpatient/outpatient MRT (Coder); an associate's degree or higher plus three years of clinical documentation improvement experience and specified coursework; Mastery Level AHIMA or AAPC certification plus two years of clinical documentation improvement experience; or clinical experience such as RN, M.D., or DO plus one year of clinical documentation improvement experience.
• For the preferred-experience pathway, have one year of creditable experience equivalent to GS-08 and specialized experience facilitating documentation quality, education, completeness, and accuracy through interaction with clinical, coding, and associated staff.
• Have at least one of the listed credentials: CIC, CPC, CCS, CCS-P, CDEI, CDIP, RHIT, RHIA, CCDS, or CCDS-O.
• Complete required background/security investigation and online onboarding.
• Meet the VA health care personnel seasonal influenza vaccination requirement.
• Serve a two-year trial period, during which continued employment is evaluated.
• Submit all application requirements specified in the announcement.
• If relying on education, use education recognized by the U.S. Department of Education from an accredited institution; foreign education requires a Certificate of Foreign Equivalency and transcript.

Nice To Haves

• One year of creditable experience equivalent to GS-08, including specialized experience improving documentation quality, education, completeness, and accuracy through interaction with clinical, coding, and associated staff.
• Knowledge of medical terminology and expert-level understanding of inpatient and outpatient medical coding as applied to health records.
• Clinical validation experience and knowledge of clinical criteria.
• At least one of the listed credentials: CIC, CPC, CCS, CCS-P, CDEI, CDIP, RHIT, RHIA, CCDS, or CCDS-O.

Responsibilities

• Review health records for the overall quality and completeness of clinical documentation.
• Apply clinical and coding knowledge to ensure documentation supports appropriate code selection and accurate reporting of healthcare data.
• Collaborate with clinical staff through written, verbal, or electronic clarification requests and queries.
• Review documentation for inpatient and outpatient episodes of care, including admissions and discharges, observation, emergency department or urgent care, and clinic visits.
• Prepare and conduct provider education on health record documentation and its effects on coding, workload, quality measures, reimbursement, and funding.
• Educate providers on complete documentation, appropriate selection of Evaluation and Management, CPT, and ICD-10 diagnosis codes, and documentation supporting the highest degree of specificity.
• Apply accepted coding practices, guidelines, and conventions when verifying diagnosis, operation, procedure, ancillary, and E/M codes.
• Review VERA input concerning missed documentation opportunities and coordinate provider education with the VERA Coordinator.
• Search patient health records for documentation supporting code assignments.
• Use computer and electronic health record applications, encoder tools, and/or CDI product suites in daily work.
• Maintain an active intra-departmental training program for HIM staff; identify training needs and provide training materials, orientation, and in-service education.
• Work with physicians, caregivers, and HIM coding staff to improve the quality, completeness, and accuracy of health record documentation and ensure documentation reflects services rendered.
• Provide continuing education to the patient care team on accurate clinical information used to measure and report physician and medical center outcomes.
• Identify documentation trends and opportunities for improvement, and support clinical staff with documentation issues.
• Assist in developing guidelines for data compatibility, consistency, and compliance monitoring to improve clinical, financial, and administrative data quality.
• Advise on health record documentation matters, including documentation requirements, liability, advance directives, informed consent, privacy and confidentiality, and state reporting.
• Analyze processes and recommend documentation improvements or changes.
• Compile, review, abstract, analyze, and interpret medical data related to patient care and treatment.
• Perform other duties as assigned.

Benefits

• Federal employee benefits package available to the employee and family, subject to position and eligibility.
• Selected applicants may qualify for credit toward annual leave accrual based on prior federal work or military service, if requested and approved before appointment.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree