Medical Records Technician (Clinical Documentation Improvement Specialist-Outpatient)

The major duties of a Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient) include, but are not limited to, the following Reviews clinical documentation for completeness, accuracy, clarity, and specificity through concurrent and retrospective inpatient record review. Ensures documentation supports all monitored, evaluated, assessed, and treated conditions, accurately reflecting SOI, ROM, and resource use. Performs concurrent CDI reviews to improve documentation while the patient is still admitted. Applies knowledge of anatomy, physiology, disease processes, treatments, diagnostics, medications, and procedures to support accurate documentation and code selection. Collaborates with clinical staff using written, verbal, or electronic queries to clarify ambiguous or incomplete documentation. Provides education to providers on accurate, complete inpatient documentation and its impact on coding, quality, reimbursement, and funding. Reports incorrect or insufficient documentation in the electronic health record. Follows inpatient coding guidelines to verify appropriate diagnosis and procedure code selection and maintains compliance with regulatory updates. Uses EHR applications, encoders, CDI software, and tools such as Outlook, Excel, Word, and Access. Develops and delivers documentation training sessions, workshops, and briefings for clinical and HIM staff. Assists in developing guidelines for data consistency, compatibility, and compliance to support clinical, administrative, and financial accuracy. Provides expertise on documentation requirements, privacy, confidentiality, informed consent, liability issues, and reporting mandates. Work Schedule: Monday - Friday 8:00am - 4:30pm Remote: This position is designated as remote. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs). Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized