Medical Records Technician (Clinical Documentation Improvement Specialist (Outpatient/Inpatient))

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.

01Basic 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. 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).

02Grade 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; OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

03Preferred Experience

One year of creditable experience equivalent to the next lower grade level GS-08 and meet specialized experience 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.

Creditable experience that indicates knowledge of medical terminology, expert level understanding of inpatient and outpatient medical coding as it applies to the health record, clinical validation experience, and knowledge of clinical criteria are preferred. The candidate is required to have at least one of the following credentials for this position CIC, CPC, CCS, CCS-P, CDEI, CDIP, RHIT, RHIA, CCDS, CCDS-O.

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.

04Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service

Total Rewards of a Allied Health Professional Duties to include but not limited to: 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. 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.

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. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.

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 Ensures active intra-departmental training program is in place for the HIM staff.

Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in inservice programs conducted throughout the hospital.

Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.

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. Collaboratively works with the professional clinical staff and provides support and education on documentation issues.

Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided.

As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc. 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.

Other duties as assigned. Work Schedule: Monday thru Friday 7:00am to 3:30pm Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Telework: Ad-Hoc Virtual: This is not a virtual position. Functional Statement #: 260550-F Permanent Change of Station (PCS): Not Authorized