Medical Records Technician
About The Position
The Medical Records Technician (MRT-CDIS) will assist the RNA accountable for using a variety of collaborative strategies with Physicians, the Clinical Documentation multi-disciplinary team members, the Facility Revenue Management team, and Health Information Management staff. Will collaborate with health care providers and licensed independent providers through written, verbal, or electronic clarification requests or queries. As subject matter experts of documentation, they are to reference or cite the facility's SOP, CDI Program Guides, serving as primary tools used by CDI to improve clinical documentation in the health record. Will use clinical knowledge and critical thinking skills when reviewing episodes of care. Will also provide education to licensed independent providers, allied health professionals, and coding staff on clinical documentation integrity issues. Provider education is a key component of all CDI programs. Shall develop the facility's CDI management program that encompasses inpatient and outpatient billable and non-billable services. CDIS specialists are to be focused on inpatient cases called patient treatment files (PTFs) and outpatient abstracts on the development, such as, but not limited to, CDI charter, Standard Operating Procedures, workflow, and turnaround time to comply with Clinical Documentation Integrity strategies. Shall develop and implement active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences). Will provide training in small or large groups, educating clinical staff about current documentation standards and improving techniques, including accurate and ethical documentation practices. CDIS, both inpatient and outpatients, shall develop and implement Standard Operating Procedure workflow, templates consistent with the most current standards of The Joint Commission, unless otherwise stated. CDI specialists shall develop an improvement plan to focus on updating problem lists of Scientific Nomenclature of Medicine – Clinical Terminologist (SNOMED-CT) consistent with ICD-10-CM code sets, predominantly outpatient abstracts. CDI Specialists shall be familiar with VHA Reconciliation which is also a critical CDI activity. This process must be professional and collaborative in nature with a goal of exchanging knowledge to ensure the complete and accurate coding of the inpatient encounter.
Requirements
- At least two years of experience in a hospital setting.
- At least two years of CDI experience.
- Certifications obtained from American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC), and/or Association of Clinical Documentation Integrity Specialists (ACDIS).
Nice To Haves
- A bachelor's degree is preferred.
Responsibilities
- Assist the RNA accountable for using a variety of collaborative strategies with Physicians, the Clinical Documentation multi-disciplinary team members, the Facility Revenue Management team, and Health Information Management staff.
- Collaborate with health care providers and licensed independent providers through written, verbal, or electronic clarification requests or queries.
- Reference or cite the facility's SOP, CDI Program Guides, serving as primary tools used by CDI to improve clinical documentation in the health record.
- Use clinical knowledge and critical thinking skills when reviewing episodes of care.
- Provide education to licensed independent providers, allied health professionals, and coding staff on clinical documentation integrity issues.
- Develop the facility's CDI management program that encompasses inpatient and outpatient billable and non-billable services.
- Focus on inpatient cases called patient treatment files (PTFs) and outpatient abstracts on the development, such as, but not limited to, CDI charter, Standard Operating Procedures, workflow, and turnaround time to comply with Clinical Documentation Integrity strategies.
- Develop and implement active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences).
- Provide training in small or large groups, educating clinical staff about current documentation standards and improving techniques, including accurate and ethical documentation practices.
- Develop and implement Standard Operating Procedure workflow, templates consistent with the most current standards of The Joint Commission, unless otherwise stated.
- Develop an improvement plan to focus on updating problem lists of Scientific Nomenclature of Medicine – Clinical Terminologist (SNOMED-CT) consistent with ICD-10-CM code sets, predominantly outpatient abstracts.
- Be familiar with VHA Reconciliation which is also a critical CDI activity.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
