Medical Records Technician

Role: Responsible for reviewing and analyzing health records to identify documentation improvement opportunities in inpatient and outpatient settings. Develops and implements clinical documentation improvement (CDI) programs, standard operating procedures, workflows, and templates aligned with current standards. Communicates with healthcare providers through queries to clarify clinical documentation and participates in reconciliation activities to correct coding discrepancies. Monitors CDI metrics, conducts program evaluations, and generates reports. Engages in collaborative meetings with healthcare teams and administrators.

Qualifications & Skills

• Associate's degree required; Bachelor's preferred
• Current certification from AHIMA, AAPC, or ACDIS
• At least two years of experience as a Clinical Documentation Integrity Specialist
• Strong knowledge of medical terminology, coding principles, and healthcare documentation standards
• Experience with electronic health records like VistA/CPRS preferred
• Understanding of MS-DRG, coding guidelines, and clinical documentation requirements
• Knowledge of healthcare regulations, including The Joint Commission, CMS, and VHA directives
• Ability to perform physical activities such as sitting, standing, lifting (up to 50 lbs), and other mobility tasks
  
  

Note: No sponsorship available. All candidates will be considered regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.