Clinical Documentation Improvement Specialist (CDIS)

U.S. Department of Veterans Affairs; Kansas City (MO); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Telework: Available

Job summary

The Medical Records Technician (CDIS) at the Kansas City VA Medical Center analyzes health records to ensure accurate documentation for ICD, CPT, and HCPCS coding. The role requires knowledge of medical terminology, anatomy, physiology, and coding guidelines, with responsibilities to educate staff on proper documentation and coding practices.

Ideal candidates should have a health information management degree or AHIMA/AAPC certification and experience with clinical documentation improvement

Qualifications

• Knowledge of medical terminology, anatomy, physiology, pathology, coding, and health records structure.
• Ability to collect and analyze data and present results.
• Strong understanding of coding rules and documentation requirements.

Responsibilities

• Review overall quality and completeness of clinical documentation for inpatient and outpatient encounters.
• Educate clinical staff on documentation processes and coding impact on reimbursement and quality measures.
• Prepare provider education on documentation in health records and coding practices.
• Monitor regulatory requirements affecting coded information and ensure proper documentation.

Skills

Medical terminology

Education

Associate degree in health information technology/health information management

AHIMA coding program

Job description

The Medical Records Technician (CDIS) at the Kansas City VA Medical Center analyzes health records to ensure accurate documentation for ICD, CPT, and HCPCS coding. The role requires knowledge of medical terminology, anatomy, physiology, and coding guidelines, with responsibilities to educate staff on proper documentation and coding practices.

Ideal candidates should have a health information management degree or AHIMA/AAPC certification and experience with clinical documentation improvement