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Medical Records Tech

2 months ago

Tuscaloosa, United States Veterans Health Administration Full time

Duties to include but not limited to:

Coder/CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations.
Recommend and/or update medical center policy memoranda pertaining to documentation improvement.
Serve as technical expert in health record content and documentation requirements.
Responsible for performing reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
Responsible to obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary.
Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements.
Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.


Work Schedule: Monday-Friday 8:00 am to 4:30 pm
Financial Discloser Report: Not required