Medical Records Technician (CDIS Outpatient)

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

The major duties of a Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Outpatient) include, but are not limited to, the following:

• Reviews the overall quality and completeness of clinical documentation in electronic health records.
• 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 proper code selection.
• Reviews clinical documentation and provides education to clinical staff on outpatient episodes of care including observation, emergency department/urgent care, and clinic visits.
• 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.
• Supports the CDI Nurse Advisor in presenting education to providers about the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of outpatient services provided by the CVHCS.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• 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.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and PowerPoint; competent in use of the health record applications (VistA and CPRS) as well as the encoder 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 HIM staff.
• Ensures active intra-departmental training program is in place for the HIM staff.
• Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding/ CDI staff to ensure clinical documentation and services rendered to patients is complete and accurate.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis, in partnership with the CDI Nurse Advisor. Identifies trends and/or opportunities to improve clinical documentation.
• Works with the professional clinical staff and provides support and education on documentation issues.
• Provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary.
• Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Reviews the health record and discusses the case with the clinical staff. Performs chart reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Work Schedule: Monday- Friday, 8:00am- 4:30pm, alternate schedules negotiable

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized