Medical Records Technician (Clinical Documentation Improvement Specialist)(CDIS - Inpatient)

U.S. Department of Veterans Affairs; Tulsa (OK); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Competitive salary

PTO 37–50 days/year

Federal retirement plan

Job summary

James Mountain Inhofe VA Medical Center in Oklahoma is seeking an Allied Health professional to strengthen veteran care through clinical documentation integrity. The role emphasizes concurrent chart review, education of providers and staff, and adherence to coding standards to ensure accurate, specific coding for inpatient episodes.

You will work with VISTA/CPRS systems, coordinate with the VERA program, and stay current with regulatory changes affecting documentation and reimbursement.

Responsibilities

• Review the overall quality and completeness of clinical documentation.
• Inpatient CDI focuses on concurrent review of patient records to improve documentation while in-house.
• Apply knowledge of medical terminology, anatomy, physiology, disease processes, treatments, tests, medications, and coding principles.
• Provide education to clinical staff on inpatient episodes of care and the need for accurate documentation.
• Educate providers on documentation to support codes with specificity.
• Adhere to coding guidelines to ensure ethical, accurate coding.
• Review VERA input and coordinate clinician education with the VERA coordinator.
• Monitor regulatory and policy changes affecting coded information across VA services.
• Assist staff with documentation requirements to reflect care accurately.
• Provide technical support on regulations, coding, supervision, reimbursement, nomenclature, and sequencing.
• Report incorrect documentation or codes in the EHR and query staff as needed.
• Utilize Outlook, Excel, Word, Access; proficient with VISTA, CPRS, and encoder tools.
• Develop training sessions to meet HIM staff objectives and data quality goals.
• Contribute to guidelines for data compatibility and monitoring for quality and compliance.
• Review DRG and LOS information to reflect illness severity and resource use.
• Assist providers with ICD, CPT, and DRG methodologies for accurate encounter reflection.
• Handle additional duties as assigned; schedule is Monday–Friday, 8:00 a.m.–4:30 p.m.

Job description

Summary

Join us in shaping the future at the brand-new James Mountain Inhofe VA Medical Center! We're seeking talented Allied Health professional to make a difference in Veteran care. In 2021 - Congress approved federal funding for a new Veterans Hospital in Tulsa which will be the first hospital to be built under the Communities Helping Invest through Property and Improvements Needed for Veterans Act of 2016.

• Total Rewards of a Allied Health Professional Major Duties and Responsibilities: Responsible for reviewing the overall quality and completeness of clinical documentation
• Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house
• Applies comprehensive knowledge of medical terminology - anatomy & physiology - disease processes - treatment modalities - diagnostic tests - medications - procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection
• Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care
• Provides education to providers on the need for accurate and complete documentation in the health record - ensuring documentation supports the codes selected to the highest degree of specificity
• Adheres to accepted coding practices - guidelines and conventions to ensure ethical - accurate - and complete coding
• Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator
• Ensures documentation supports codes based on guidelines specific to certain diagnoses - procedures - and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided
• provides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencing
• Reports incorrect documentation or codes in the electronic patient health record
• Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation
• Uses a variety of computer applications in day to day activities and duties - such as Outlook - Excel - Word - and Access
• competent in use of the health record applications (VISTA and CPRS) as well as the encoder product suite
• Develops and conducts seminars - workshops - short courses - informational briefings - and conferences concerned with health record documentation - educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff
• Assists in the development of guidelines for data compatibility - consistency - and monitoring for compliance to improve the quality for clinical - financial - and administrative data to ensure that all information is fully documented and supported
• Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation - lab results - diagnostic information and treatment to ensure documentation reflects severity of illness - acuity and resource consumption
• The documentation specialist is a member of the healthcare team - and as such - shall assist all clinical providers with ICD - CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter
• Additional duties may be assigned as determined necessary for the service
• Work Schedule: Monday - Friday
• 8:00 a.m
• - 4:30 p.m .Location: You may temporarily work at Jack C
• Montgomery VA Medical Center at 1011 Honor Heights Drive - Muskogee - OK 74401 until the completion of the new hospital in Tulsa - at which point your duty station will change to the new Tulsa location James Mountain Inhofe VAMC 440 South Houston Avenue - Tulsa - Oklahoma 74127
• Pay: Competitive salary and regular salary increases
• Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child
• Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
• Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
• Telework: Not authorized
• Virtual: This is not a virtual position
• Functional Statement #: 54280-A.