Medical Records Technician (CDIS)

U.S. Department of Veterans Affairs; Washington (District of Columbia); On-site; USD 69,000 - 91,000; Full time

Job summary

An established industry player is seeking a dedicated Medical Records Technician to join their Health Administration department. This role involves ensuring the accuracy of clinical documentation and educating staff on coding practices. The ideal candidate will have a strong background in medical coding and possess relevant certifications. You will work in a collaborative environment, promoting high-quality health records and compliance with coding regulations. If you are passionate about healthcare documentation and eager to make a difference, this opportunity is perfect for you.

Qualifications

• U.S. citizenship required and selective service registration for males.
• Certification in medical coding through AHIMA or AAPC is mandatory.

Responsibilities

• Review clinical documentation for quality and completeness.
• Conduct provider education on documentation processes.
• Maintain data to track coding practices and report findings.

Skills

Medical terminology

Clinical documentation

Coding practices

Provider education

Data analysis

Education

Certification through AHIMA or AAPC

Relevant experience in medical coding

Tools

Outlook

Excel

Word

Access

VistA

CPRS

Job description

Join to apply for the Medical Records Technician (CDIS) role at U.S. Department of Veterans Affairs

Pay Range

This range is provided by the U.S. Department of Veterans Affairs. Your actual pay will depend on your skills and experience. Talk with your recruiter to learn more.

Base pay range: $69,923.00/yr - $90,898.00/yr

Summary

This position serves as the Medical Records Technician (CDIS) within the Health Administration department at the Washington DC VA Medical Center VA Health Care System.

Duties

1. Review the quality and completeness of clinical documentation.
2. Apply knowledge of medical terminology, anatomy & physiology, disease processes, treatment, diagnostics, medications, procedures, and health services principles to ensure proper code selection.
3. Review clinical documentation and educate clinical staff on inpatient and outpatient care documentation, including admissions, discharges, observation, emergency, and clinic visits.
4. Conduct provider education on documentation processes, emphasizing the impact on coding, workload, quality measures, reimbursement, and funding.
5. Adhere to coding practices, guidelines, and conventions for diagnosis, procedures, and evaluations to ensure ethical and accurate coding.
6. Monitor regulatory and policy changes affecting coded information across services.
7. Assist staff with documentation requirements to reflect patient care accurately and completely.
8. Search patient records to justify code assignments based on organizational knowledge.
9. Use applications like Outlook, Excel, Word, Access, VistA, CPRS, and encoder products in daily activities.
10. Develop and conduct training sessions, seminars, and workshops on health record documentation.
11. Ensure ongoing training for HIM staff and meet training needs of other hospital personnel.
12. Promote high-quality, accurate health record documentation through interaction with physicians and care teams.
13. Maintain data to track coding practices and report findings to management.
14. Strive for optimal payment without violating regulatory guidelines (e.g., upcoding, DRG creep).

Work Schedule

Monday - Friday, 7:30am - 4:00pm

Telework

Not available

Position Type

In-person, not virtual

Requirements

• U.S. citizenship required.
• Selective Service registration for males born after 12/31/1959.
• Proficiency in English.
• Subject to background/security checks.
• Complete online onboarding and provide identification documents.
• Participation in influenza vaccination program required.

Qualifications

Applicants must meet basic education, experience, and certification requirements, including:

• U.S. citizenship.
• Relevant experience or education in medical coding and health records.
• Certification through AHIMA or AAPC.

Additional Information

Details on service credit, education recognition, benefits, and application procedures are provided, along with links to standards and further resources.