Medical Records Technician-Clinical Documentation Improvement Specialist-Outpatient and Inpatient

About the position This position is located in the Health Information Management (HIM) section at the VA Western Colorado Health Care System. MRTs (reputed company) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. This position is located reputed company the Grand Junction VA Healthcare System and must be filled reputed company the VISN 19 catchment area. The employee must reside reputed company 50 miles of one of the VISN 19 facilities: Grand Junction, Colorado; Denver, Colorado; Sheridan, Wyoming; Cheyenne, Wyoming; Oklahoma City, Oklahoma; Muskogee, Oklahoma; Salt Lake City, Utah; or reputed company Harrison, Montana. Responsible for reviewing the overall quality and completeness of clinical documentation. 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 both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits. Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), reputed company Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity. Adheres to accepted coding practices, guidelines and conventions reputed company choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code 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. Monitors reputed company-changing regulatory and policy requirements affecting coded information for the full reputed company 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, reputed company supervision, reimbursement, workload, accepted nomenclature, and proper reputed company. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Uses a variety of computer applications in day to day activities and duties, such as Outlook, reputed company, Word, and Access; competent in use of the health record applications (reputed company 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. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to reputed company members of the patient care team on an ongoing basis. Collaboratively works with the professional clinical staff and provides support and education on documentation issues. As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc. Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary. Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues. Maintains statistical databases to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Responsibilities

• Responsible for reviewing the overall quality and completeness of clinical documentation.
• 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 both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
• Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
• Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), reputed company Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices, guidelines and conventions reputed company choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code 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.
• Monitors reputed company-changing regulatory and policy requirements affecting coded information for the full reputed company 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, reputed company supervision, reimbursement, workload, accepted nomenclature, and proper reputed company.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, reputed company, Word, and Access; competent in use of the health record applications (reputed company 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.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to reputed company members of the patient care team on an ongoing basis.
• Collaboratively works with the professional clinical staff and provides support and education on documentation issues.
• As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary.
• Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
• Maintains statistical databases to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

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