Medical Records Technicians (CDIS - Inpatient) classify medical data from patient health records in hospital and physician-based settings. The role focuses on reviewing, abstracting, and coding diagnoses and procedures, with an emphasis on clinical documentation improvement and accurate health record coding.
Key responsibilities include:
- Reviewing inpatient and outpatient clinical documentation for completeness, accuracy, and specificity.
- Identifying ambiguous, conflicting, incomplete, or nonspecific provider documentation and issuing clarification requests or queries.
- Assigning appropriate ICD, CPT, HCPCS, and E/M codes in accordance with accepted coding guidelines and conventions.
- Educating providers and clinical staff on documentation practices, coding impacts, reimbursement, workload, and quality measures.
- Supporting clinical documentation improvement efforts through rounds, seminars, workshops, and informational briefings.
- Tracking coding trends and maintaining statistical databases to validate program performance and reporting.
Requirements & Qualifications
Basic requirements
- U.S. citizenship is required.
- Must be proficient in written and spoken English.
- One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records; or
- An associate's degree in health information technology/health information management or a related field with qualifying coursework; or
- Completion of an AHIMA-approved coding program or equivalent intensive coding training program; or
- An acceptable combination of education and experience.
- Certification must be held from AHIMA, AAPC, ACDIS, or equivalent qualifying credentials for the role.
GS-9 qualifications
- One year of experience equivalent to the journey level of a Medical Records Technician (Coder-Inpatient); or
- An associate's degree or higher plus three years of clinical documentation improvement experience; or
- Mastery-level certification plus two years of clinical documentation improvement experience; or
- Clinical experience such as RN, MD, or DO plus one year of CDI experience.
Required knowledge and skills
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology.
- Ability to collect, analyze, and present data in various formats.
- Strong written and verbal communication skills with providers.
- Knowledge of healthcare documentation regulations and coding systems, including ICD-CM, ICD-PCS, CC/MCC, MS-DRG, and POA indicators.
- Knowledge of severity of illness, risk of mortality, and complexity of care.
- Ability to conduct training and continuing education for staff development.
Preferred experience
- At least 2 years of experience preferred.
Benefits & Perks
Benefits and perks
- Competitive salary and regular salary increases.
- Paid time off: 37-50 days annually, including annual leave, sick leave, and federal holidays.
- Potential credit toward annual leave accrual based on prior experience or military service.
- Paid parental leave after 12 months of employment.
- Child care subsidy for eligible full-time employees.
- Federal retirement plan with pension and 401(k) with VA matching contributions.
- Federal health, vision, dental, term life, and long-term care insurance.
- Remote work eligible.
- Predictable schedule and mission-driven federal workplace benefits.
Location
N/A
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$61,722 - $80,243
Remote work allowed
Yes
Posted
4 weeks ago
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