Medical Records Technician (Clinical Documentation Improvement Specialist - Inpatient)

Department of Veterans Affairs•Lexington, KY

46d

About The Position

The Inpatient CDIS serves as the liaison between Health Information Management and clinical staff. They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports service rendered to patients, appropriate workload is captured, and resources are properly allocated. Major duties for the Medical Records Technician (CDIS - Inpatient) include, but are not limited to: Responsible for reviewing the overall quality and completeness of clinical documentation. Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. The goal of these reviews is to-ensure that all conditions monitored, evaluated, assessed and treated, or that impact the patient's care are documented as completely and precisely as possible and supported by the clinical indicators present in the health record. This helps to capture the patient's true risk of mortality (ROM)/severity of illness (SOI), supports resource consumption, and enhances continuity of care. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house. Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure clinical documentation supports proper code selection and reporting of high quality healthcare data. Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries. Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care. Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. Documentation must support the care provided as well the health status of the patient. Any clinical indicators not supported by the patient's condition for the current episode of care or encounter must not be introduced solely to increase financial reimbursement. Provides education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation in the electronic patient health record. Adheres to accepted coding practices, guidelines, and conventions when verifying the most appropriate diagnosis, operation, or procedure code to ensure ethical, accurate, and complete coding. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the VERA program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation. Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite. Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. Ensures active intra-departmental training program is in place for the HIM staff. Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital.

Responsibilities

Responsible for reviewing the overall quality and completeness of clinical documentation.
Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure clinical documentation supports proper code selection and reporting of high quality healthcare data.
Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.
Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care.
Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
Provides education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
Reports incorrect documentation in the electronic patient health record.
Adheres to accepted coding practices, guidelines, and conventions when verifying the most appropriate diagnosis, operation, or procedure code to ensure ethical, accurate, and complete coding.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator.
Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite.
Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
Ensures active intra-departmental training program is in place for the HIM staff.
Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital.