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

Veterans Health Administration • Kansas City, MO

13d • Hybrid

About The Position

The Medical Records Technician (Clinical Documentation Improvement Specialist) works in the Health Information Management Section of the Business Operations Service at the Kansas City VA Medical Center. The role reviews and analyzes inpatient and outpatient medical records and encounter forms to assess the quality and completeness of clinical documentation. The incumbent ensures diagnoses and conditions are documented by providers in the proper sequence and that procedures and evaluation and management services are documented appropriately.

The position applies knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, coding standards, and documentation requirements. It includes educating clinical staff and providers on documentation practices and how documentation affects coding, workload, quality measures, reimbursement, and funding. The specialist also monitors changing regulatory and policy requirements and develops and conducts educational sessions for staff.

The work schedule is Monday through Friday, 7:30 a.m. to 4:00 p.m. Telework is available; this is not a virtual position. A retention incentive may be authorized for highly qualified candidates. Relocation assistance is not authorized.

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 one of the basic qualification pathways: one year of creditable relevant experience; an eligible associate's degree; completion of an eligible AHIMA-approved or other intensive coding training program; or an accepted combination of education and experience.
• Possess either an AHIMA or AAPC mastery-level certification, or a clinical documentation improvement certification through AHIMA or ACDIS. Listed certifications include CCS, CCS-P, RHIT, RHIA, CPC, COC, CIC, CDIP, and Certified Clinical Documentation Specialist.
• For GS-9, meet one of the stated experience pathways: one year of creditable experience equivalent to GS-8 MRT (Coder-Outpatient and Inpatient); an associate's degree or higher and three years of CDI experience with specified coursework; mastery-level certification and two years of CDI experience; or clinical experience such as RN, MD, or DO and 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 and identify opportunities for more precise or complete documentation.
• Demonstrate ability to collect and analyze data and present results in various formats.
• Demonstrate ability 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 and clinical classification systems, including ICD-CM and PCS, CPT, and HCPCS; CC/MCC, MS-DRG structure, and POA indicators.
• Demonstrate knowledge of inpatient severity of illness, risk of mortality, and complexity of care, and outpatient CPT Evaluation and Management criteria for selecting appropriate E/M codes.
• Demonstrate knowledge of training methods and teaching skills sufficient to conduct continuing education and staff development.
• Meet federal pre-employment conditions, including a background/security investigation, onboarding requirements, acceptable identification, and a pre-employment physical evaluation or examination.
• Register for Selective Service if applicable to male applicants born after December 31, 1959.
• Participate in the VA seasonal influenza vaccination program.
• Serve a one- or two-year trial period, during which continued employment is evaluated.
• Use only education or degrees recognized by the U.S. Department of Education from accredited institutions; foreign education requires the specified equivalency documentation if used to qualify.

Nice To Haves

• Two to three years of concurrent or retrospective clinical documentation improvement experience in an inpatient/outpatient acute care facility.

Responsibilities

• Review the overall quality and completeness of clinical documentation.
• Conduct quantitative and qualitative reviews and analyses of inpatient and outpatient medical records and encounter forms.
• Ensure diagnoses and conditions for which care is rendered are documented by providers in the proper sequence, and that procedures and evaluation and management services are documented.
• Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures when reviewing records.
• Review clinical documentation and educate clinical staff on inpatient and outpatient episodes of care, including admissions and discharges, observation, emergency department and urgent care, and clinic visits.
• Prepare and conduct provider education on health-record documentation processes and the effects of documentation on coding, workload, quality measures, reimbursement, and funding.
• Monitor changing regulatory and policy requirements that affect coded information.
• Develop and conduct seminars, workshops, short courses, informational briefings, and conferences on health-record documentation and educational and functional training requirements.
• Collect and analyze data and present results in appropriate formats, potentially to different organizational levels.
• Maintain verbal and written communication with providers.

Benefits

• Competitive salary and regular salary increases; a higher step rate may be considered for higher or unique qualifications or VA needs.
• 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 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; many federal insurance programs can be carried into retirement.
• Prior work or military service may qualify for annual-leave accrual credit, subject to request and approval before appointment and not guaranteed.
• A retention incentive may be authorized for highly qualified candidates.

What This Job Offers

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