Medical Records Technician

Job Description

Job Description

Overview

Ansible Government Solutions, LLC (Ansible) is seeking multiple Medical Records Technicians to work with us in support of the Orlando VA Medical Center located at 13800 Veterans Way Orlando, FL 32827. The schedule is typically Monday-Friday, 7:30am-4pm. If you accept employment with Ansible, you must also acknowledge that any assigned schedule is subject to change at the direction of either Ansible or its customers.

Ansible is a Service-Disabled Veteran-Owned Small Business (SDVOSB) providing Federal customers with solutions in many arenas. Our customers face wide-ranging challenges in the fields of health care, national security, and information technology. To address these challenges, we employ intelligent and committed staff who take care of our customers’ success as if it is their own.

Duties and Responsibilities

• Review and analyze health records to identify documentation improvement opportunities in both inpatient and outpatient settings
• Generate and communicate queries to healthcare providers to clarify clinical documentation
• Develop the facility's CDI management program encompassing both inpatient and outpatient billable and non-billable services
• Focus on inpatient cases (patient treatment files/PTFs) and outpatient abstracts
• Develop standard operating procedures (SOPs), workflow processes, and templates consistent with current standards
• Implement an improvement plan focused on updating problem lists or Scientific Nomenclature of Medicine – Clinical Terminologies (SNOMED-CT) consistent with ICD-10 CM code sets
• Participate in reconciliation activities to review discrepancies in code or MS-DRG assignments
• Conduct program evaluation and performance improvement activities
• Monitor and report on key CDI metrics, including query rates, response rates, and impact measures
• Generate and deliver periodic reports (weekly, bi-monthly, and monthly) as required
• Participate in collaborative meetings with healthcare teams and administrators

Qualifications and Requirements

• Bachelor's degree preferred (Associate's degree minimum)
• Current certification from American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC) and/or Association of Clinical Documentation Integrity Specialists (ACDIS)
• Minimum of two years' experience as a Clinical Documentation Integrity Specialist
• Strong knowledge of medical terminology, coding principles, and healthcare documentation standards
• Experience with electronic health record systems like VistA/CPRS preferred
• Understanding of MS-DRG assignment, coding guidelines, and clinical documentation requirements
• Familiarity with The Joint Commission, CMS regulations, and VHA directives related to health information management
• No sponsorship available

All candidates must be able to:

• Sit, stand, walk, lift, squat, bend, twist, and reach above shoulders during the work shift
• Lift up to 50 lbs from floor to waist
• Lift up to 20 lbs
• Carry up to 40 lbs a reasonable distance
• Push/pull with 30 lbs of force

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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