Responsible for reviewing the overall quality and completeness of clinical documentation within the Health Information Management (HIM) section at the Columbia VA Health Care System.
Reviews inpatient and outpatient records concurrently or retrospectively to identify ambiguous, conflicting, incomplete, or nonspecific provider documentation.
Improves the accuracy and specificity of documentation to support proper code selection, quality reporting, reimbursement, funding, and continuity of care.
Collaborates with clinical staff through written, verbal, and electronic clarification requests and provides provider education on documentation practices.
Supports ethical, accurate, and complete coding by applying accepted coding guidelines and monitoring regulatory and policy changes affecting coded information.
Work schedule: Monday through Friday, 8:00 a.m. to 4:30 p.m.
United States citizenship is required.
English language proficiency required.
Applicants must meet one of the following basic qualification paths:
- One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records structure/format
- Associate degree in health information technology, health information management, or a related field with at least 12 semester hours in HIT/HIM coursework
- Completion of an AHIMA-approved coding program or comparable intensive coding training program
- Equivalent combinations of education and experience
Additional qualifying requirements include six months of creditable experience equivalent to a Medical Records Technician (Coder).
Certification required:
- Apprentice/Associate-level certification through AHIMA or AAPC, or
- Mastery-level certification through AHIMA or AAPC, or
- Clinical Documentation Improvement certification through AHIMA or ACDIS
For GS-09 consideration, applicants must meet one of the following:
- One year of experience equivalent to the journey level of a MRT (Coder-Outpatient and Inpatient)
- Associate degree or higher plus three years of CDI experience
- Mastery-level certification plus two years of CDI experience
- Clinical experience such as RN, M.D., or DO plus one year of CDI experience
Competitive salary and regular salary increases
37-50 days of annual paid time off per year, including annual leave, sick leave, and federal holidays
Paid parental leave after 12 months of employment
Child care subsidy eligibility for qualified employees
Traditional federal pension and federal 401(k) with VA contributions up to 5%
Federal health, vision, dental, term life, and long-term care insurance options
Location
South Carolina, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$61,722 - $76,128
Remote work allowed
No
Posted
3 days ago