Clinical Documentation Improvement Specialist (CDIS)

U.S. Department of Veterans Affairs; Kansas City (MO); On-site; USD 60,000 - 78,000; Full time

Benefits offered by this job

Federal benefits

Paid time off

Retirement plan

Job summary

U.S. Department of Veterans Affairs in Kansas City seeks a Medical Records Technician (CDIS) to analyze patient records, ensure complete documentation, and code diagnoses and procedures accurately.

The role includes educating staff and monitoring regulatory coding requirements across inpatient and outpatient encounters. The position emphasizes knowledge of medical terminology, anatomy, pathology, and coding standards, with responsibilities spanning education, documentation review, and part-time

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Associate's degree with 12 semester hours in health information technology/health information management or related courses.
• Completion of an AHIMA approved coding program or equivalent with courses in anatomy, physiology, medical terminology, and basic coding.

Responsibilities

• Review medical records to ensure accurate diagnoses, procedures, and documentation are coded properly.
• Educate clinical staff on documentation and coding practices to improve accuracy and compliance.
• Provide provider education on documentation impact on coding, workload, and reimbursement.
• Monitor regulatory requirements affecting coded information and maintain knowledge of ICD-CM, PCS, CPT, and HCPCS rules.

Skills

Medical terminology

Anatomy & physiology

Pathophysiology

Medical coding

Health records

Coding rules & ICD/CPT/HCPCS

Data analysis

Verbal/written communication

Education

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

AHIMA/AAPC certification eligibility (Mastery Level or CDI)

Clinical Documentation Improvement Certification (CDIP/CDS)

Job description

U.S. Department of Veterans Affairs in Kansas City seeks a Medical Records Technician (CDIS) to analyze patient records, ensure complete documentation, and code diagnoses and procedures accurately.

The role includes educating staff and monitoring regulatory coding requirements across inpatient and outpatient encounters. The position emphasizes knowledge of medical terminology, anatomy, pathology, and coding standards, with responsibilities spanning education, documentation review, and part-time