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

  JOB REQUIREMENTS: Duties Major duties include, but are not limited to:Responsible for reviewing the overall quality and completeness ofclinical documentation. Reviews clinical documentation and provideseducation to clinical staff on both inpatient and outpatient episodes ofcare including admissions and discharges, observation, emergencydepartment/urgent care, and clinic visits. Prepare and conduct providereducation on documentation processes in the health record to include theimpact of documentation on coding, workload, quality measures,reimbursement, and funding. Provides education to providers on the needfor accurate and complete documentation in the health record,appropriate code selection of Evaluation and Management (E/M), CurrentProcedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuringdocumentation supports the codes selected to the highest degree ofspecificity. Reviews VERA input on missed opportunities in providerdocumentation identified by the VERA coordinator and coordinate providerdocumentation education with the VERA coordinator. Monitorsever-changing regulatory and policy requirements affecting codedinformation for the full spectrum of services provided by the VAMC.Assists facility staff with documentation requirements to completely andaccurately reflect the patient care provided Provides technical supportin the areas of regulations and policy, coding requirements, residentsupervision, reimbursement, workload, accepted nomenclature, and propersequencing. Ensures provider documentation is complete and supports thediagnoses and procedures coded. Directly consults with the professionalstaff for clarification of conflicting or ambiguous clinical data.Reports incorrect documentation or codes in the electronic patienthealth record. Searches the patient health record to find documentationjustifying code assignment based on an expanded knowledge of theorganization and structure of the patient record. Uses a variety ofcomputer applications in day to day activities and duties, such asOutlook, Excel, Word, and Access Develops and conducts seminars,workshops, short courses, informational briefings, and conferencesconcerned with health record documentation, educational and functionaltraining requirements to ensure program objectives are met for clinicaland Health Information Management (HIM) staff Ensures activeintra-departmental training program is in place for the HIM staff.Determines and meets training needs of extra-departmental professional,para-professional and... For full info follow application link. TheUnited 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/F5055FDE7CFD45D9

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