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 a 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 an 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
• Participates in clinical rounds and may - where appropriate - offer information on documentation - coding rules and reimbursement issues
• 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.
• 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…