Medical Records Technician Coder (Clinical Documentation Improvement Specialist) Details

Medical Records Technician Coder (Clinical Documentation Improvement Specialist)

US Department of Veterans Affairs - Kansas City, MO

Employment Type : Full-Time

DutiesSummary

This announcement is open and continuous. Candidates will be reviewed and referred as applicable periodically as positions are available. You will receive updates on your status via email.


Responsibilities

The Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS) is located within the Health Information Management Section (HIMS) of the Business Operations Service (BOS) at the Kansas City VA Medical Center (KCVAMC).


Incumbent provides quantitative and qualitative review and analysis of medical records and encounter forms of both inpatient and outpatient encounters to ensure all diagnoses and conditions for which care is being rendered are documented by the provider in the proper sequence, and procedures have been documented and/or evaluation and management services.Major Duties include, but are not limited to:

• Analyzes physician queries as initiated by the coders, to identify those areas of documentation needing further clarification, to improve patient care and documenting trends by provider, clinic, and ancillary services for future in-service sessions, to ensure proper revision of problematic processes, forms, etc;
• Utilizes knowledge of the VHA Resident Supervision Documentation Guidelines, the Joint Commission, Centers for Medicare and Medicaid Services (CMS), and VA guidelines on medical record functions;
• Develops, completes, and coordinates internal monitoring and auditing activities to oversee compliance with documentation, coding, and billing issues and maintain reports of auditing activities, as well as follow-up reports when necessary;
• Assists with formal external reviews including but not limited to QuadraMed, Joint Commission, External Peer Review Program (EPRP), Office of Inspector General (OIG), System-wide Ongoing Assessment and Review Strategy (SOARS), Proclarity and VSSC;
• Assists in providing training process of encoder software, diagnosis/procedure code assignments, regulatory compliance, and data quality goals;
• Meets with Registered Nurse (Informatics) and other clinical providers, reviews documentation and coding, provides feedback concerning audits and monitors, and prepares formal reports for providers, clinical service chiefs and other facility leadership;
• Prepares and presents formal educational presentations to providers.
Work Schedule: Full Time, Monday-Friday 8:00 am to 4:30 pm
This is not a Virtual position. However, this position may be authorized for Telework.
Functional Statement Title/#: Clinical Documentation Specialist GS-0675
Travel Required

Not required

Supervisory status

No

Promotion Potential

None

• Job family (Series)

  0675 Medical Records Technician

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• Requirements

  RequirementsConditions of Employment
  • You must be a U.S. Citizen to apply for this job
  • Designated and/or random drug testing may be required
  • Selective Service Registration is required for males born after 12/31/1959
  • You may be required to serve a probationary period
  • Subject to a background/security investigation
  • Must be proficient in written and spoken English
  • Selected applicants will be required to complete an online onboarding process
  QualificationsTo qualify for this position, applicants must meet both basic requirements and grade determinations by the closing date of this announcement, 12/31/2021.
  
  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.
  • Experience or Education. Candidates must meet one of the following:(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'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,(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. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series must have Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • English Language Proficiency. MRT (CDIS) employees 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).
  
  Grade Determinations: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-9. Candidates must meet one of the experience requirements and certification and must demonstrate the KSAs.
  • Experience. One year of creditable experience equivalent to the journey grade level of a GS-8 MRT (Coder-Outpatient and Inpatient). This experience is described as: independently selects and assigns codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records; reviews and abstracts clinical data from the record for documentation of diagnoses and procedures; consults with clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. 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.
  • 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: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii. 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. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. iv. Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. 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. vii. 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. viii. 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 G57 dated December 10, 2019.
  
  Physical Requirements: Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices. 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: http://ope.ed.gov/accreditation/. 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

  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. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. 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.
  
  It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
  
  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.
  
  Veterans and Transitioning Service Members: Please visit the VA for Vets 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.
  
  If you are unable to apply online view the following link for information regarding an Alternate Application.

  
  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.
  
  If applicants are interviewed for the position, performance-based interview questions will be used. For additional information regarding performance-based interviews, please review the following website on the internet: http://www.va.gov/pbi. In addition, candidates may be interviewed by a panel.
  
  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.
  

  Background checks and security clearanceSecurity clearance

  Other

  Drug test required

  No

  Position sensitivity and risk

  Non-sensitive (NS)/Low Risk

  Trust determination process

  Suitability/Fitness

• Required Documents

  Required Documents

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

  • Resume
  , and Clinical Documentation Improvement Certification through AHIMA or ACDIS (copy required).
  
  VA Form 10-2850c Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search. (Required upon selection)
  
  Your resume must provide your full name, mailing address and day/evening phone numbers, highest federal civilian grade held; for each work experience, list job title (include series/grade if Federal Job), duties and accomplishments, employer's name/address, supervisor's name/phone number, starting and ending dates (month/year), hours per week and salary.
  
  The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist 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.
  
  
  • Cover Letter
  • DD-214/ Statement of Service
  • Disability Letter (VA)
  • License
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS
  • Performance Appraisal
  • Professional Certification
  • Resume
  • SF-15
  • 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 http://www.fedshirevets.gov/job/vetpref/index.aspx.
  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 schools accredited by accrediting institutions recognized by the U.S. Department of Education.

  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.

• Benefits

  Benefits

  A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits.

  Review our benefits

  Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.

• The public

  U.S. citizens, nationals or those who owe allegiance to the U.S.

US Citizens