Medical Records Tech (CDIS In/Out PAT)
DutiesMajor duties and responsibilities of the position:
Responsible for reviewing the overall quality and completeness of clinical documentation for both inpatient and outpatient.
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 proper code selection.
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.
Prepare and conduct provider education on documentation processes in the health record and the appropriate code selection and ensuring documentation supports the codes selected to the highest degree of specificity.
Adheres 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 coding.
Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
Ensures provider documentation is complete and supports the diagnoses and procedures coded.
Reports incorrect documentation or codes in the electronic patient health record.
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.
Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
Develops and conducts educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
Ensures active intra-departmental training program is in place for the HIM staff.
Determines 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 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.
Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary.
May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation.
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.
Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
The CDIS is expected to strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines.
Selection of the principal diagnosis and principal procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set (UHDDS).
Performs other related duties as assigned.
Work Schedule:
M-F 8am-4:
30pm EST.
Virtual:
This is a virtual position.
Functional Statement #:
21P02-A Relocation/Recruitment Incentives:
Not Authorized Permanent Change of Station (PCS):
Not Authorized RequirementsConditions 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.
Must pass pre-employment evaluation.
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See Additional Information below for details.
QualificationsBasic Requirements:
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 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).
Grade Determinations:
(a) 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.
(b) Certification.
Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.
Mastery Level Certification.
This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC.
To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation.
Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications.
Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies.
However, current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).
Clinical Documentation Improvement Certification.
This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS).
To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation.
Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies.
However, current Clinical Documentation Improvement Certifications include:
Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
(c) 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, Part II, Appendix G57.
The full performance level of this vacancy is GS-9.
Physical Requirements:
Work is sedentary but also demands standing, walking, bending, twisting, and carrying light items.
EducationIMPORTANT:
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 informationThis 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.
Pursuant to VHA Directive 1193.
01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.
e.
, medical, religious or pregnancy).
VHA HCPs do not include remote workers who only infrequently enter VHA locations.
If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date.
The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
Responsible for reviewing the overall quality and completeness of clinical documentation for both inpatient and outpatient.
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 proper code selection.
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.
Prepare and conduct provider education on documentation processes in the health record and the appropriate code selection and ensuring documentation supports the codes selected to the highest degree of specificity.
Adheres 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 coding.
Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
Ensures provider documentation is complete and supports the diagnoses and procedures coded.
Reports incorrect documentation or codes in the electronic patient health record.
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.
Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
Develops and conducts educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
Ensures active intra-departmental training program is in place for the HIM staff.
Determines 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 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.
Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary.
May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation.
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.
Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
The CDIS is expected to strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines.
Selection of the principal diagnosis and principal procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set (UHDDS).
Performs other related duties as assigned.
Work Schedule:
M-F 8am-4:
30pm EST.
Virtual:
This is a virtual position.
Functional Statement #:
21P02-A Relocation/Recruitment Incentives:
Not Authorized Permanent Change of Station (PCS):
Not Authorized RequirementsConditions 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.
Must pass pre-employment evaluation.
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See Additional Information below for details.
QualificationsBasic Requirements:
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 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).
Grade Determinations:
(a) 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.
(b) Certification.
Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.
Mastery Level Certification.
This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC.
To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation.
Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications.
Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies.
However, current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).
Clinical Documentation Improvement Certification.
This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS).
To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation.
Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies.
However, current Clinical Documentation Improvement Certifications include:
Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
(c) 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, Part II, Appendix G57.
The full performance level of this vacancy is GS-9.
Physical Requirements:
Work is sedentary but also demands standing, walking, bending, twisting, and carrying light items.
EducationIMPORTANT:
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 informationThis 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.
Pursuant to VHA Directive 1193.
01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.
e.
, medical, religious or pregnancy).
VHA HCPs do not include remote workers who only infrequently enter VHA locations.
If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date.
The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
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