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Medical Records Technician Cdis
Medical Records Technician Cdis-March 2024
Milwaukee
Mar 31, 2026
About Medical Records Technician Cdis

  JOB REQUIREMENTS: Duties This position is located in the HealthInformation Management (HIM) section at the VA Ann Arbor HealthcareSystem. Medical Record Technician (Coders) are skilled in classifyingmedical data from physician offices, group practices, multi-specialtyclinics and specialty centers. These coding practitioners analyze andabstract patient\'s health records, and assign alpha-numeric codes foreach diagnosis and procedure. To perform this task, they must possessexpertise in International Classification of Diseases (ICD), CurrentProcedural Terminology (CPT), and the Healthcare Common Procedure CodingSystem (HCPCS). MRT (Coder) may also provide education related to codingand documentation. Major Duties include, but are not limited to:Responsible for reviewing the overall quality and completeness ofclinical documentation. Inpatient CDI focuses on the concurrent reviewof patient records with an emphasis on improving documentation while thepatient is still in-house while outpatient CDI focuses on improvingclinical staff documentation of outpatient encounters throughretrospective, ideally prior to coding and billing, review of outpatientencounters and extensive provider education. Applies comprehensiveknowledge of medical terminology, anatomy & physiology, diseaseprocesses, treatment modalities, diagnostic tests, medications,procedures as well as the principles and practices of health servicesand the organizational structure to ensure proper code selection.Reviews clinical documentation and provides education to clinical staffon both inpatient and outpatient episodes of care including admissionsand discharges, observation, emergency department/urgent care, andclinic visits. Prepare and conduct provider education on documentationprocesses in the health record to include the impact of documentation oncoding, workload, quality measures, reimbursement, and funding. Provideseducation to providers on the need for accurate and completedocumentation in the health record, appropriate code selection ofEvaluation and Management (E/M), Current Procedural Terminology (CPT)and ICD-10 diagnosis codes, and ensuring documentation supports thecodes selected to the highest degree of specificity. Adheres to acceptedcoding practices, guidelines and conventions when choosing the mostappropriate diagnosis, operation, procedure, ancillary, or evaluationand management (E/M) code to ensure ethical, accurate, and completecoding. Reviews VERA input on missed opportunities in providerdocumentation identified by... For full info follow application link.The United States Government does not discriminate in employment on thebasis of race, color, religion, sex (including pregnancy and genderidentity), national origin, political affiliation, sexual orientation,marital status, disability, genetic information, age, membership in anemployee organization, retaliation, parental status, military service,or other non-merit factor. ***** APPLICATION INSTRUCTIONS: ApplyOnline: ipc.us/t/460BD96DEC4A4E4A

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