Medical Records Technician CDIS (Outpatient)

SummaryThis position is in the Health Information Management (HIM) section at the Lebanon VA Medical Center. MRT CDIS (Outpatient) 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.QualificationsApplicants pending the completion of educational or certification/licensure requirements may be referred to and tentatively selected but may not be hired until all requirements are met.Basic RequirementsUnited States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA PolicyExperience: One year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of health records: Education: An Associates Degree from an accredited college or university recognized by the US 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/heath information management (e.g. - - courses in medical terminology - anatomy - physiology - medical coding and introduction to health records (Transcripts Required)OR Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvementOR - Clinical experience - such as Registered Nurse (RN) - Medical Doctor (M.D.) - or Doctor of Osteopathy (DO) - and one year of experience in clinical documentation improvementThe training program must have led to eligibility for coding certification/certification examination - and the sponsoring academic institution must have been accredited by a national US Department of Education accreditor - or comparable international accrediting authority at the time the program was completed (Transcripts Required)Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirementsThe following experience and 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 proceduresAlso - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 USC 7403(f) 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 ACDISNOTE: Mastery level certification is required for all positions above the journey levelhowever - for clinical documentation improvement specialist assignments - a clinical documentation improvement certification may be substituted for a mastery level certificationMay 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)In addition to the basic requirement you must also meet the grade requirement/certification requirement and knowledge skill and abilities (KSAs) listed below: Grade Determinations for the GS-9 MRT CDIS (Outpatient): Qualified applicants must demonstrate one year of experience equivalent to the next lower grade MRT (Coder-Outpatient GS-8 and demonstrate the additional knowledge - skills and abilities at the MRT (CDIS-Outpatient) GS-9. GS-9 MRT CDIS (Outpatient) Experience: 1One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient)OR 2An 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 3Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvementOR4Clinical experience - such as RN - M.D. - or DO - and one year of experience in clinical documentation improvementCertification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certificationIn addition to the experience above - the candidate must demonstrate the following knowledge - skills - and abilities (KSAs): 1Knowledge of coding and documentation concepts - guidelines - and clinical terminology2Knowledge 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 record3Ability to collect and analyze data and present results in various formats - which may include presenting reports to various organizational levels4Ability to establish and maintain strong verbal and written communication with providers5Knowledge of regulations that define healthcare documentation requirements - including The Joint Commission - CMS - and VA guidelines6Extensive knowledge of coding rules and regulations - to include current clinical classification systems such as ICD - CPT and HSCPCS7Knowledge 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 provided8Knowledge of training methods and teaching skills is sufficient to conduct continuing education for staff developmentThe training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issuesReferences: VA Handbook 5005/79 - Part II - Appendix G57 MEDICAL RECORD TECHNICIAN Qualification StandardThe full performance level of this vacancy is GS-9. Physical Requirements: Work is primarily sedentaryEmployees generally sit to do the workThere may be some walking - standing - or carrying light items such as patient charts/ records - manuals or filesEmployees also extract information from computer systems which requires ability to utilize keyboards or other similar devices.DutiesDuties include but are not limited to: Responsible for reviewing the overall quality and completeness of clinical documentationOutpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective - ideally prior to coding and billing - review of outpatient encounters and extensive provider educationApply 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 selectionReviews 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 visitsPrepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding - workload - quality measures - reimbursement - and fundingProvides education to providers on the need for accurate and complete documentation in the health record - appropriate code selection of Evaluation and Management (E/M) - Current Procedural Terminology (CPT) and ICD-10 diagnosis codes - and ensuring documentation supports the codes selected to the highest degree of specificityAdheres 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 codingReviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinatorEnsures 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 needsMonitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMCTimely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programsAssist facility staff with documentation requirements to completely and accurately reflect the patient care providedprovides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencingEnsure provider documentation is complete and supports the diagnoses and procedures codedDirectly consults with the professional staff for clarification of conflicting or ambiguous clinical dataReports incorrect documentation or codes in the electronic patient health recordExpertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient recordQueries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentationDevelops 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) staffEnsures active intra-departmental training program is in place for the HIM staffDetermines 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 hospitalWork Schedule: Monday - Friday8:00 a.m- 4:30 p.mCompressed/Flexible: Authorized Telework: Not Authorized Virtual: This is not a virtual positionFunctional Statement #: 00000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized