Medical Records Technician (Clinical Documentation Integrity Specialist (Outpatient and Inpatient))

This position is located in the Health Information Management (HIM) section at the Martinsburg VA Medical Center. MRTs (Coder) 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. PRINCIPALES MISSIONS : Total Rewards of a Allied Health Professional Duties to include but not limited to: 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 clinical documentation supports proper code selection and reporting of high quality healthcare data. Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries. 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), 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 when verifying the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding. Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator. 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, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite Ensures active intra-departmental training program is in place for the HIM staff. Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in inservice programs conducted throughout the hospital. Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis. Identifies trends and/or opportunities to improve clinical documentation. Collaboratively works with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative dat

Salaire : $70,623 – $91,815/Per Year | Avantages : http://www.vacareers.va.gov/why-choose-va/benefits/index.asp

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans? Martinsburg, WV VA Medical Center. Located in the heart of West Virginia's Eastern Panhandle, the Martinsburg Veterans Affairs Medical Center (VAMC) can be found on 175 acres in historic Berkeley County and has a service area of more than 70,000 Veterans in West Virginia, Maryland, Virginia, and Pennsylvania. The Medical Center, part of the VA North Atlantic Health Network, offers a comprehensive range of services, including internal medicine, ambulatory surgery, audiology and speech pathology, dental, nursing home, nutrition, podiatry, prosthetics, women's health, mental health and rehabilitation medicine. Patient care is provided through an integrated pr