Clinical Documentation Improvement Specialist

U.S. Department of Veterans Affairs; Atlanta (GA); A distancia; USD 65.000 - 85.000; Jornada completa

Descripción de la vacante

U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coders) at the VA Medical Center in Atlanta, GA.

The role focuses on classifying medical data from patient health records by assigning alpha-numeric codes for diagnoses and procedures, with emphasis on documentation quality and coding accuracy. Incumbents will review clinical documentation, educate staff, and coordinate between HIM and clinical teams to ensure complete and accurate health records, aligning with VERA

Formación

• Knowledge of medical terminology, anatomy, physiology and disease processes.
• Familiarity with health services and coding conventions to ensure accurate coding.
• Ability to educate and liaise with clinical staff on documentation and coding practices.

Responsabilidades

• Review the overall quality and completeness of clinical documentation.
• Provide education to clinical staff on documentation for inpatient and outpatient care.
• Educate providers on documentation needs and the impact on coding, workload and reimbursement.
• Coordinate between health information management and clinical staff to improve documentation quality.
• Review documentation to ensure accurate severity of illness, risk of mortality, and resource use.
• Query clinical staff to clarify ambiguous documentation and drive corrective actions.
• Assist with seminars and trainings on health record documentation.

Conocimientos

Medical terminology

Anatomy & physiology

Documentation quality

Coding practices

Descripción del empleo

U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coders) at the VA Medical Center in Atlanta, GA.

The role focuses on classifying medical data from patient health records by assigning alpha-numeric codes for diagnoses and procedures, with emphasis on documentation quality and coding accuracy. Incumbents will review clinical documentation, educate staff, and coordinate between HIM and clinical teams to ensure complete and accurate health records, aligning with VERA