CDI Specialist: Inpatient & Outpatient Documentation

Veterans Health Administration; Tampa (FL); Hybrid; USD 62,000 - 80,000; Full time

Job summary

Veterans Health Administration's James A. Haley VA hospital in Tampa seeks a Medical Records Technician (CDIS) to support outpatient and inpatient CDI efforts and ensure accurate documentation for coding and reimbursement.

The CDIS reviews records, discusses documentation with clinicians, and uses VistA/CPRS and encoder tools to improve specificity and medical necessity while aligning with VERA guidelines.

Qualifications

• Transcript must be submitted with your application if you are basing all or part of your qualifications on education.
• Foreign education must include a Certificate of Foreign Equivalency with your transcript to receive credit.

Responsibilities

• Review documentation in inpatient and outpatient records to identify opportunities for documentation improvement.
• Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
• Apply coding guidelines to determine principal/secondary diagnoses and procedures for accurate DRG assignment.
• Provide education to providers on documentation impact to coding, quality measures, and reimbursement.

Job description

Veterans Health Administration's James A. Haley VA hospital in Tampa seeks a Medical Records Technician (CDIS) to support outpatient and inpatient CDI efforts and ensure accurate documentation for coding and reimbursement.

The CDIS reviews records, discusses documentation with clinicians, and uses VistA/CPRS and encoder tools to improve specificity and medical necessity while aligning with VERA guidelines.