Medical Records Technician (CDIS-Outpatient and Inpatient)

Full Job Description

This position is in the Health Information Management (HIM) section at the Columbia VA Health Care System.

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.

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: (1) Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.

OR, (2) Education: An associate degree from an accredited college or university recognized by the U.S.

Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, (3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding.

The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S.

Department of Education accreditor, or comparable international accrediting authority at the time the program was completed.

OR, (4) Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.

(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S.

Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures.

Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

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

Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC.

(2) Mastery Level Certification through AHIMA or AAPC. (3) 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.

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.

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-09 Experience.

One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient); 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. Preferred Experience: None.

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-08.

The actual grade at which an applicant may be selected for this vacancy is the GS-09.

Physical Requirements: This work requires some physical exertion such as prolonged periods of standing, bending, reaching, crouching, stooping, stretching, and lifting moderately heavy items such as manuals, record boxes, equipment or assisting patients.

See https://dvagov.sharepoint.com/sites/OCHCO/SitePages/D5019.aspx VA Directive and Handbook 5019, Employee Occupational Health Service for requirements. Major Duties:

Total Rewards of a Allied Health Professional Duties include, but not 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.

The goal of these reviews is to ensure that all conditions monitored, evaluated, assessed and treated, or that impact the patient's care are documented as completely and precisely as possible and supported by the clinical indicators present in the health record.

This helps to capture the patient's true risk of mortality (ROM)/severity of illness (SOI), supports resource consumption, and enhances continuity of care.

Inpatient COi focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house.

Outpatient COi focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education.

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 clinical documentation supports proper code selection and reporting of high-quality healthcare data.

Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.

Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.

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

Documentation must support the care provided as well as the health status of the patient.

Any clinical indicators not supported by the patient's condition for the current episode of care or encounter must not be introduced solely to increase financial reimbursement.

Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), CPT and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.

Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.

Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation in the electronic patient health record.

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

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Work Schedule: Monday - Friday, 8:00am - 4:30pm.

Work Schedule is subject to change based on agency need. Recruitment Incentive (Sign-on Bonus): Not Authorized. Permanent Change of Station (Relocation Assistance): Not Authorized.

Pay: Competitive salary and regular salary increases.

When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

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) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.

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. Functional Statement #: 61015F. Permanent Change of Station (PCS): Not Authorized.