Medical Records Technician CDIS - Outpatient

Full Job Description

This position is located in the Health Information Management (HIM) section at the. VA Medical Center.

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Experience and Education: Experience: .One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR, Education: An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR, Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.

Certification: Persons hired, reassigned, or promoted to MRT (CDIS Outpatient) positions in the GS-0675 series in VHA must have either below: Mastery Level Certification through AHIMA or AAPC.

Clinical Documentation Improvement Certification through AHIMA or ACDIS.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers.

An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment.

At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)), GS-9 Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR, An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; NOTE: See paragraph 2g for a detailed definition of mastery level certification; OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

(b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology.

Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record, including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record.

Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.

Ability to establish and maintain strong verbal and written communication with providers.

Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.

Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD and CPT, and HCPCS.

Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.

Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.

The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.

Preferred Experience: In an acute healthcare system in inpatient and outpatient ICD-10 and CPT coding for a minimum of 2 years.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-9.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

****All required documentation must be uploaded before the announcement closes, to support eligibility.**** Failure to submit documentation will constitute the application being categorized as incomplete and therefore ineligible for referral.

Experience must be clearly indicated in your resume. Major Duties:

Major duties and responsibilities include, but may not be limited to: Responsible for reviewing the overall quality and completeness of clinical documentation.

Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation.

Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection and reporting high-quality healthcare data.

Reviews clinical documentation and provides education to clinical staff on outpatient episodes of care.

Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.

Provides education to providers on the need for accurate and complete documentation in the health record, to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.

Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.

Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.

Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite.

Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.

Ensures active intra-departmental training program is in place for the HIM staff.

Determines and meets training needs of extra-departmental professional, para-professional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.

Identifies trends and/or opportunities to improve clinical documentation. Collaboratively works with the professional clinical staff and provides support and education on documentation issues.

Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported.

Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Performs other duties as required.

Total Rewards of a Allied Health Professional Work Schedule: Monday - Friday; 8:00 am - 4:30 pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position.

Permanent Change of Station (PCS): Not Authorized