CDISs must be able to perform all duties of an MRT (Coder-Inpatient). The CDI Specialist serves as a consultant to various medical staff and ad hoc committees related to medical documentation activities, including compliance. They serve on various workgroups and teams as assigned. They are also responsible for reports preparation and presentation of data to the committee(s). Serves as a consultant in the development and updating of Medical Center policy memoranda pertaining to document function and medical record activities. Ensures that medical record documentation activities are consistent with the requirements established by VA manuals and directives and the Joint Commission standards and Scoring Guidelines.
They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. The CDI Specialist analyzes, interprets, and trends findings of quality improvement monitors and prepares monthly/quarterly reports for presentation to the medical staff and/or management. Based on these findings, makes recommendations, and persuades physicians/service chiefs to adopt proposals that result in necessary policy or procedural changes. The CDI Specialist must possess thorough knowledge of medical, terminology, anatomy and physiology and practical knowledge of medical treatment modalities, procedures, surgeries, and disease processes. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. Serves as Subject Matter Expert for HIMS regarding medical record documentation. Develops and maintains collaborative relationships with physicians, service chiefs, and other medical center staff at all organizational levels. Must possess effective interpersonal skills.
Responsible for determining the need for and extent of training medical staff personnel regarding medical record document and requirements. May be required to develop training materials and continuing education programs. Training programs may include legal and ethical documentation practices, Evaluation and Management Code assignment, medical record documentation requirements, etc. In cases where additional medical record documentation is necessary, incumbent advises and/or discusses the issue with the responsible physician(s) via query. Queries sent to clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. Evaluates, monitors, and reports on data from a variety of sources in relation to inpatient and outpatient reimbursement. These sources include Data Validation outputs and data provided from the local VISTA and VA Central Office. Incumbent will conduct monitors, summarize data, and prepare reports in a variety of areas, including a variety of special projects for the HIMS section.
Performs other related duties and responsibilities as assigned by the Chief, HIMS or designee.
Work Schedule: Monday-Friday 8:00AM-4:30PM
Compressed/Flexible: Not Authorized
Virtual: This is a virtual position.
Functional Statement #: 554-60217-0 Medical Records Technician Clinical Document Improvement Specialist (Inpatient) GS-0675-09
Financial Disclosure Report: Not required
Starting at $59,966 Per Year (GS 9)
