Medical Records Technician (Clinical Documentation Improvement Specialist)(CDIS - Inpatient)

Veterans Health Administration • Tulsa, OK

2d • Onsite

About The Position

The Medical Records Technician (Clinical Documentation Improvement Specialist—CDIS, Inpatient) reviews inpatient clinical documentation for quality and completeness, with concurrent review intended to improve records while patients are still in the hospital. The specialist uses knowledge of medical terminology, anatomy and physiology, disease processes, treatment, diagnostic tests, medications, procedures, health services, and coding practices to support accurate code selection and documentation at the highest degree of specificity.

The role provides education and technical support to providers and other clinical and Health Information Management staff on documentation, coding, regulations, policy, reimbursement, workload, nomenclature, sequencing, resident supervision, and related requirements. The specialist reviews documentation and coding, identifies and reports errors, queries clinicians when clarification is needed, and supports documentation requirements connected with VERA, DRGs, severity of illness, acuity, length of stay, and resource consumption. The position also monitors changing regulatory and policy requirements and helps develop data-quality guidelines and training activities.

The position is scheduled Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is not authorized, and the position is not virtual. The employee may initially work at the Jack C. Montgomery VA Medical Center in Muskogee, Oklahoma, until the new James Mountain Inhofe VA Medical Center in Tulsa is completed; the duty station will then change to the Tulsa location.

The vacancy is at the GS-9 level, above the full-performance level. Applicants must meet the stated basic experience, education, or combination pathways and hold an eligible coding or clinical documentation improvement certification. The role requires one of the listed GS-9 qualification pathways, such as relevant inpatient coder experience, specified education and CDI experience, mastery-level certification with CDI experience, or clinical experience with CDI experience. Employees must also demonstrate the listed knowledge, skills, and abilities in coding, clinical interpretation, regulations, communication, analysis, and training.

Requirements

• Meet the basic qualification requirement through one of the stated pathways: one year of relevant experience; a qualifying associate’s degree; completion of an eligible coding training program; or an accepted combination of education and experience.
• Have an eligible apprentice/associate-level or mastery-level certification through AHIMA or AAPC, or a clinical documentation improvement certification through AHIMA or ACDIS. For this CDI assignment, a CDI certification may substitute for mastery-level certification.
• Meet one of the stated GS-9 qualification pathways: one year of creditable experience equivalent to journey-level inpatient MRT (Coder); an associate’s degree or higher plus three years of CDI experience and specified coursework; mastery-level AHIMA or AAPC certification plus two years of CDI experience; or clinical experience such as RN, M.D., or DO plus one year of CDI experience.
• Demonstrate knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Demonstrate knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret health-record information, including laboratory and test results, and identify documentation opportunities.
• Be able to collect and analyze data and present results in various formats, including reports to different organizational levels.
• Be able to establish and maintain strong verbal and written communication with providers.
• Demonstrate knowledge of healthcare documentation regulations, including The Joint Commission, CMS, and VA guidelines.
• Demonstrate extensive knowledge of coding rules and regulations, current clinical classification systems including ICD-CM and PCS, CC/MCC, MS-DRG structure, and POA indicators.
• Demonstrate knowledge of severity of illness, risk of mortality, and complexity of care.
• Demonstrate knowledge of training methods and teaching skills sufficient to conduct staff development and continuing education.
• Be a U.S. citizen, proficient in written and spoken English, and comply with applicable background, onboarding, identification, influenza-vaccination, and application-document requirements.
• Serve a one- or two-year trial period, subject to the stated evaluation and written certification requirements.

Responsibilities

• Review inpatient clinical documentation for quality and completeness through concurrent patient-record review.
• Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatment, diagnostic tests, medications, procedures, and coding principles to support accurate code selection.
• Educate clinical staff and providers on inpatient documentation and the need for accurate, complete, and specific health-record documentation.
• Adhere to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding.
• Review VERA input on missed provider-documentation opportunities and coordinate documentation education with the VERA coordinator.
• Ensure documentation supports codes under requirements used to classify VA patients for the Veterans Equitable Resource Allocation program.
• Monitor regulatory and policy requirements affecting coded information across the facility’s services.
• Assist facility staff with documentation requirements and provide technical support on regulations, policy, coding, resident supervision, reimbursement, workload, nomenclature, and sequencing.
• Report incorrect documentation or codes in the electronic patient health record and query medical staff or other caregivers when clarification is needed.
• Use computer applications and health-record systems, including Outlook, Excel, Word, Access, VISTA, CPRS, and the encoder product suite.
• Develop and conduct seminars, workshops, short courses, informational briefings, and conferences on health-record documentation and education or functional training requirements.
• Assist in developing guidelines for data compatibility, consistency, and compliance monitoring to improve clinical, financial, and administrative data quality.
• Review the appropriateness of working DRG and length-of-stay information using clinical documentation, lab results, diagnostic information, and treatment.
• Assist clinical providers with ICD, CPT, and DRG methodologies so documentation accurately reflects the encounter.
• Perform additional duties as assigned by the service.

Benefits

• Competitive salary and regular salary increases.
• 37–50 days of annual paid time off per year, consisting of 13–26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.
• Up to 12 weeks of paid parental leave after 12 months of employment in connection with the birth, adoption, or foster-care placement of a child.
• Eligible full-time employees may qualify for a childcare subsidy after 60 days of employment, subject to family-income and other eligibility limits.
• Traditional federal pension, with five-year vesting, and federal 401(k) with VA contributions of up to 5%.
• Federal health, vision, dental, term-life, and long-term-care insurance programs; many federal insurance programs can be carried into retirement.
• Possible annual-leave accrual credit based on prior federal work or military service, if requested and approved before appointment.

What This Job Offers

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