Medical Record Technician/Coder (CDIS, Outpatient and Inpatient)

Summary

The Medical Record Technician/Coder (Clinical Documentation Improvement Specialist - Outpatient/Inpatient) position is located in the Health Information Management Division of the Resources Directorate located at the Captain James A. Lovell Federal Health Care Center. This position maintains the quality of patient records, assigning of appropriate International Classification of Diseases, Current Procedural Terminology & Healthcare Common Procedure Coding System codes & other duties as assigned.

This job is open to

Clarification from the agency

Open to current VISN 12 employees. First consideration may be given to FHCC employees.

Duties

CDISs must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient). CDISs:

Serve as the liaison between health information management and clinical staff.

Responsible for facilitating improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated.

Review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.

Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients.

Develop and/or update medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements.

Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.

Review appropriateness of and responses to queries through review of query reports.

Review health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership.

Obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.

Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements.

Monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education.

Responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met.

Provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices.

Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures in order to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. Work Schedule: Monday-Friday, 0730-1600

Telework: Ad-hoc

Virtual: This is not a virtual position.

Functional Statement #: 000000

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

Financial Disclosure Report: Not required

Requirements

Conditions of Employment

You must be a U.S. Citizen to apply for this job.

Selective Service Registration is required for males born after 12/31/1959.

Must be proficient in written and spoken English.

You may be required to serve a probationary period.

Subject to background/security investigation.

Selected applicants will be required to complete an online onboarding process.

Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

Qualifications

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:

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:

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.

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:

Apprentice/Associate Level Certification through AHIMA or AAPC.

Mastery Level Certification through AHIMA or AAPC.

Clinical Documentation Improvement Certification through AHIMA or ACDIS.

English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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 and Inpatient)), GS-9

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.

Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. NOTE: See paragraph 2g and 2h for a detailed definition of mastery level certification and 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 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.

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.

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. References: VA Handbook 5005/122 PART II APPENDIX G57The full performance level of this vacancy is GS-9.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: . If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: .

Additional information

Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Required Documents

To apply for this position, you must provide a complete Application Package which includes:

Resume

SF-50/ Notification of Personnel Action

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

License

Other (1)

Professional Certification

Resume

Separation Notice (RIF)

SF-50/ Notification of Personnel Action

Transcript

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit .

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from .

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.