Medical Records Technican (Clinical Documentation Improvement Specialist - Outpatient and Inpatient)

Medical Records Technican (Clinical Documentation Improvement Specialist - Outpatient and Inpatient) Department: Department of Veterans Affairs This position is located within the Department of Veterans Affairs(VA), Veterans Health Administration(VHA), James A. Haley VA hospital. Clinical Documentation Integrity Specialists(CDIS) must be able to perform all duties of MRT(Coder-outpatient and Inpatient). CDIS's serve as the liaison between Health Information Management and clinical staff. Key Responsibilities Clinical Documentation Improvement Specialists (CDIS) review documentation in the medical record and information in an inpatient Patient Treatment File (PTF) and in outpatient encounters and facilitate modifications to the health record to identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity and accurately address all acute and chronic conditions. Other Duties and Functions include but are not limited to: Serve as a technical expert in health record content and documentation requirements. Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. Review appropriateness of and responses to queries through the review of query reports. Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of inpatient records with an emphasis on improving documentation while the patient is still in-house while Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective review of outpatient encounters. Provides education to the providers on documentation improvement in the health record to include the impact of documentation on coding, quality measures and reimbursement. Reviews 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 Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the facility. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Queries providers for clarification of conflicting or ambiguous documentation. Identifies trends and opportunities to improve documentation. Uses a variety of computer applications in daily activities and duties, such as Outlook, Excel, Word, and Power Point and is competent in the use of the health record applications VistA and CPRS as well as the Solventum encoder product suite and WebVIRR suite of products for PTF completion, Encounter Completion and Compliance E-mail Tracking. Work Schedule: Monday- Friday: 7:30a.m to 4:00 p.m. Telework: Ad-hoc Virtual: This is not a virtual position. Functional Statement #: 70210F Requirements & Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: Which agency is hiring for this position? This position is with Veterans Health Administration, Department of Veterans Affairs. What is the salary for this position? The posted pay range is $61722 – $80243/yr. Is this position remote or telework eligible? This position is eligible for telework. What is the application deadline? Applications close on 2026-10-26. Who is eligible to apply? This position is open under the 'Public' hiring path. #J-18808-Ljbffr Veterans Health Administration