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

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.

Duties

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.

Qualifications

Basic Requirements- Experience and Education - Experience.- One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR Education - An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records). (A transcript must be submitted with your application if you are basing all or part of your qualifications on education). OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed. OR Experience/Education Combination. - Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical 4 terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder) Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Master