CDIS: Medical Records & Clinical Documentation Expert

US-Department-of-Veterans-Affair; Kansas City (MO); On-site; USD 52,000 - 76,000; Full time

Job summary

The U.S. Department of Veterans Affairs is seeking a Medical Records Technician (CDI Specialist) in Health Information Management. The role covers analyzing patient records, abstracting clinical information, and assigning ICD, CPT, and HCPCS codes for diagnoses and procedures.

Emphasis on medical coding standards and documentation requirements. Required are a relevant associate degree or AHIMA/AAPC training, plus one year of related experience.

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, medical coding, and the structure and format of a health record.
• Completion of AHIMA approved coding program or equivalent training leading to coding certification eligibility.
• Equivalent combinations of education and experience acceptable as substitutions for basic requirements.

Responsibilities

• Analyze patient health records and abstract clinical information.
• Assign accurate ICD, CPT, and HCPCS codes for diagnoses and procedures.
• Educate staff on proper coding and documentation practices when required.

Skills

Medical terminology

Anatomy & physiology

Clinical documentation

Data analysis

Verbal & written communication

Regulatory knowledge

AHIMA/AAPC knowledge

Education

Associate’s degree in health information technology/health information management

AHIMA coding program completion

Job description

The U.S. Department of Veterans Affairs is seeking a Medical Records Technician (CDI Specialist) in Health Information Management. The role covers analyzing patient records, abstracting clinical information, and assigning ICD, CPT, and HCPCS codes for diagnoses and procedures.

Emphasis on medical coding standards and documentation requirements. Required are a relevant associate degree or AHIMA/AAPC training, plus one year of related experience.