Medical Records Technician

Duties And Responsibilities

• Review and analyze health records to identify documentation improvement opportunities in both inpatient and outpatient settings
• Generate and communicate queries to healthcare providers to clarify clinical documentation
• Develop the facility's CDI management program encompassing both inpatient and outpatient billable and non-billable services
• Focus on inpatient cases (patient treatment files/PTFs) and outpatient abstracts
• Develop standard operating procedures (SOPs), workflow processes, and templates consistent with current standards
• Implement an improvement plan focused on updating problem lists or Scientific Nomenclature of Medicine – Clinical Terminologies (SNOMED-CT) consistent with ICD-10 CM code sets
• Conduct program evaluation and performance improvement activities
• Monitor and report on key CDI metrics, including query rates, response rates, and impact measures
• Generate and deliver periodic reports (weekly, bi-monthly, and monthly) as required
• Participate in collaborative meetings with healthcare teams and administrators

Qualifications And Requirements

• Bachelor's degree preferred (Associate's degree minimum)
• Current certification from American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC) and/or Association of Clinical Documentation Integrity Specialists (ACDIS)
• Minimum of two years' experience as a Clinical Documentation Integrity Specialist
• Strong knowledge of medical terminology, coding principles, and healthcare documentation standards
• Experience with electronic health record systems like VistA/CPRS preferred
• Familiarity with MS-DRG assignment, coding guidelines, and clinical documentation requirements
• Familiarity with The Joint Commission, CMS regulations, and VHA directives related to health information management
• No sponsorship available