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Medical Record Tech

1 month ago

Singapur, Singapore Veterans Health Administration Full time

Summary

The Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)) position is located in the Health Information Management Section (HIMS) at the VA NY Harbor HCS. The duties and responsibilities of the outpatient CDIS are carried out throughout the facility including all administrative and clinical areas involved with the service.

Duties

Major duties include but are not limited to: Reviews the overall quality and completeness of outpatient encounters. 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. Complies, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Performs chart reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the record. 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. Prepare and conduct provide 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), Current procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity. Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator. Ensures documentation supports codes. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Directly consults with staff for clarification on conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. 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 HIM staff. Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary. May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation. 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.
Work Schedule : 8:00am-4:30pm Monday-Friday
Remote: This is a remote position.
Functional Statement # : PD21P61A
Relocation/Recruitment Incentives : Not authorized
Permanent Change of Station (PCS): Not authorized
Fi nancial Disclosure Report: Not required

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