United States Department of Veterans Affairs - Sioux Falls, SD
posted 2 months ago
Part-time,Full-time - Mid Level
Onsite - Sioux Falls, SD
Administration of Human Resource Programs
About the position
The Medical Records Technician (Clinical Documentation Improvement Specialist) position at the US Veterans Health Administration involves ensuring accurate coding and documentation of patient health records. The role requires comprehensive knowledge of medical terminology, anatomy, and coding systems to support the clinical documentation process, ensuring compliance with regulations and guidelines. The technician will work closely with healthcare providers to improve documentation quality and accuracy, ultimately impacting patient care and reimbursement processes.
Responsibilities
- Apply comprehensive knowledge of medical terminology, anatomy & physiology, and coding systems to ensure proper code selection.
- Select and assign codes from ICD, CPT, and HCPCS coding systems.
- Adhere to accepted coding practices and guidelines for accurate and complete coding.
- Monitor regulatory and policy requirements affecting coded information.
- Assist facility staff with documentation requirements to reflect patient care accurately.
- Consult with professional staff for clarification of clinical data.
- Report incorrect documentation or codes in the electronic patient health record.
- Conduct seminars and workshops on health record documentation and training requirements.
- Facilitate improved quality and accuracy of health record documentation through interaction with healthcare providers.
- Develop guidelines for data compatibility and monitoring for compliance.
Requirements
- Doctoral degree in Medicine or related field.
- Knowledge of medical terminology, anatomy, physiology, and disease processes.
- Experience with medical coding and health information management.
- Certification in Clinical Documentation Improvement or equivalent.
- Proficiency in Microsoft Excel and other window-based applications.
- Strong organizational and communication skills.
Nice-to-haves
- Experience in outpatient clinical documentation improvement.
- Familiarity with VistA and CPRS health record applications.
- Teaching or training experience in health information management.
Benefits
- Comprehensive benefits package as a federal employee.
- Access to health insurance, retirement plans, and paid leave.
