Ansible Government Solutions
Location
Orlando, Florida
The Medical Records Technician will review and analyze health records to identify documentation improvement opportunities and generate queries to healthcare providers for clarification. They will also develop standard operating procedures and participate in performance improvement activities.
Candidates should have a minimum of an associate degree and current certification from relevant health information management associations. A minimum of two years' experience as a Clinical Documentation Integrity Specialist is required, along with strong knowledge of medical terminology and coding principles.
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 Participate in reconciliation activities to review discrepancies in code or MS-DRG assignments 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 Understanding of 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 All candidates must be able to: Sit, stand, walk, lift, squat, bend, twist, and reach above shoulders during the work shift Lift up to 50 lbs from floor to waist Lift up to 20 lbs Carry up to 40 lbs a reasonable distance Push/pull with 30 lbs of force All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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