Medical Records Technician (Clinical Documentation Integrity Specialist-Outpatient/Inpatient)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Salem VA Health Care System and is the Clinical Documentation Integrity Specialist (CDIS).

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: Proficient in spoken and written English as required by 38 USC 7403 (f). Experience and Education: Experience and Education: 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, Education.

An associate's 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, 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, 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: 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.

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 above, candidates must also meet any additional requirements to include KSAs based on grade assignment below.

GS-09 Grade Requirement: 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; OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement AND; Demonstrated KSAs.

In addition to the experience above, the employee must demonstrate all of the following KSAs: (1) Knowledge of coding and documentation concepts, guidelines, and clinical terminology; (2) 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; (3) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels; (4) Ability to establish and maintain strong verbal and written communication with providers; (5) Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines; (6) Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS.

They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators; (7) Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and 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 for outpatients; and (8) 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.

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

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.

The actual grade at which an applicant may be selected for this vacancy is in the GS-9 Physical Requirements: See VA Directive and Handbook 5019. This is mostly a sedentary position. Major Duties:

Major Duties and Responsibilities: Responsible for reviewing the overall quality and completeness of clinical 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 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.

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.

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.

Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates 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 VERA program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

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. Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary.

Compiles, reviews, abstracts, analyzes, and interprets medical data incidental to a variety of patient care and treatment activities.

Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay.

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.

Other duties as assigned.

Total Rewards of a Allied Health Professional Work Schedule: 7:45 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) 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: Yes.

Ad-Hoc Virtual: This is not a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized