MEDICAL RECORDS TECHNICIAN (Coder - Clinical Documentation Improvement Specialist) The incumbent acts independently to plan, organize, direct and control areas with emphasis on data validation, analysis and generation of reports associated with the facility's Health Information Management program.
Assures CPT/HCPCS and ICD-9-CM and/or ICD-10-CM/PCS codes, DRGs, and APGs are supported by clinical and physician documentation for accurate and reliable data collection and reimbursement.
Collaboratively works with the professional clinical staff and outside agencies.
The duties include, but are not limited to:
o Provides support and education on documentation issues and assists in the development of guidelines for data compatibility, consistency and monitoring to improve the quality of clinical, financial and administrative data to ensure that every part of the information is completely documented and supported.
o Ensure coded data accurately reflects service provided, based on documentation, prevention against fraud and abuse, and that the facility receives the most appropriate level of reimbursement and allocation.
o Provides technical staff support for the administration of the medical center's Health Information Management program.
o Reviews reports of unsigned progress note cases, makes appropriate adjustments, and provides technical advice and support regarding the repair of discrepancies in the documentation or the processing of billable encounters.
o Assists the healthcare team in coding with the highest degree of accuracy.
o Completes a monthly Reasons Not Billable Review and monthly Coding Audits of provider documentation for coding accuracy and documentation specificity.
These findings are reported to the Coding Supervisor and Compliance Committee.
o Develops and coordinates internal monitoring to oversee quality and education with documentation, HIMS, coding and billing issues.
o Generates, analyzes, validates, and presents reports to the Chief, HIMS and committees as needed.
o Coordinates and assists in the development of standardized, system-wide guidelines, procedures and education materials for coding and abstracting to meet the rules and regulations of governmental health programs, VA, and other external entity requirements and payers.
o Researches the impact of coding changes and issues coding alerts addressing concerns, target areas, etc.
Work Schedule:
Monday - Friday; hours negotiable Position Description Title/PD#:
Medical Records Technician (Coder - Clinical Documentation Improvement Specialist) Rotating Shift:
No Required to work Holidays and/or Weekends:
No Fair Labor Standards Act (FLSA):
Non-Exempt Bargaining Unit Position:
Yes Relocation Expenses:
Relocation expenses are not authorized for this position.

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