Med Rec Tech (CDIS In/Outpat)
Department of Veterans Affairs - Middleton, WI
posted 16 days ago
About the position
The Medical Records Technician (CDIS) position is located within the Health Information Management (HIM) section at the William S. Middleton Memorial Veterans Hospital in Madison, WI. This announcement will be used to fill vacancies at The William S. Middleton Memorial Veterans Hospital in Madison, WI. The position is permanent, full-time, and requires the technician to perform all duties of a Medical Records Technician (Coder-Outpatient and Inpatient). CDISs serve as the liaison between health information management and clinical staff, responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff. They will also develop and/or update medical center policy pertaining to clinical documentation improvement and provide training to clinical staff about current documentation standards and improvement techniques.
Responsibilities
- Perform all duties of a Medical Records Technician (Coder-Outpatient and Inpatient).
- Serve as the liaison between health information management and clinical staff.
- Facilitate improved overall quality, education, completeness, and accuracy of health record documentation.
- Review documentation and facilitate modifications to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
- Identify opportunities for documentation improvement.
- Develop and/or update medical center policy pertaining to clinical documentation improvement.
- Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
- Review appropriateness of and responses to queries.
- Collect data, graph and analyze results, create reports, and communicate findings.
- Obtain corrective action plans from responsible clinical service directors.
- Monitor trends in the industry and changes in regulations impacting coding and documentation practices.
- Develop and implement training/education programs for clinical staff.
Requirements
- Must be a U.S. Citizen.
- Proficient in written and spoken English.
- Must have either Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
- One year of creditable experience equivalent to the next lower grade level GS-08.
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology.
- Ability to collect and analyze data and present results.
- Ability to establish and maintain strong verbal and written communication with providers.
- Knowledge of regulations defining healthcare documentation requirements.
Benefits
- Comprehensive benefits package as a federal employee.
- Eligibility for annual leave accrual based on prior work experience or military service.
