Medical Records Technician – Clinical Documentation Integrity Specialist
Cetechs is seeking a dedicated Medical Records Technician Clinical Documentation Integrity Specialist (MRT-CDIS) to join our growing team at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, TN. This onsite, full-time position collaborates with the CDI Nursing Advisor to support and enhance clinical documentation quality for both inpatient and outpatient services. The MRT-CDIS is integral to ensuring the accuracy, integrity, and compliance of medical record documentation, which directly supports optimal patient care and correct reimbursement.
Location:
US-TN-Memphis
Lt. Col. Luke Weathers, Jr. VA Medical Center
116 North Pauline Street, Memphis, TN 38104
Key Responsibilities:
Review and analyze health records for documentation improvement opportunities (inpatient & outpatient).
Generate and communicate clinical queries to healthcare providers to clarify documentation.
Develop and implement the facility’s CDI management program for both billable and non-billable inpatient and outpatient services.
Focus on inpatient treatment files (PTFs) and outpatient abstracts.
Develop SOPs, workflows, and templates aligned with current standards.
Lead improvement plans updating problem lists/SNOMED-CT, consistent with ICD-10 CM codes.
Participate in code or MS-DRG assignment reconciliation activities.
Evaluate the CDI program and drive performance improvement initiatives.
Monitor and report key CDI metrics (query rates, response rates, impact measures).
Prepare and deliver required weekly, bi-monthly, and monthly reports.
Attend and actively participate in collaborative meetings with healthcare staff and administrators.
Qualifications:
U.S. citizenship and ability to obtain a Public Trust government security clearance are required.
Bachelor's degree
Current certification from one or more of: AHIMA, AAPC, or ACDIS.
At least 2 years’ experience as a Clinical Documentation Integrity Specialist.
In-depth understanding of medical terminology, coding principles, and healthcare documentation standards.
Familiarity and experience with electronic health record systems such as VistA/CPRS preferred.
Knowledge of MS-DRG assignment, coding guidelines, and clinical documentation requirements.
Familiarity with The Joint Commission, CMS, and VHA directives as related to health information management.
Schedule:
Monday–Friday, full-time (40 hours/week)
Additional Information:
This position is contingent upon contract award with an anticipated start date in the fall. Cetechs takes pride in supporting our team—if you are committed to integrity, accuracy, and teamwork, we invite you to apply and be part of our mission to enhance patient care through documentation excellence.
Cetechs is an Equal Opportunity Employer.