Medical Records Tech (CDIS Inpatient/Outpatient)

Summary This position is located in the Health Information Management (HIM) section at the Tomah VA Medical Center. MRTs CDIS 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. Responsibilities These coding practitioners analyze and abstract patients health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Major duties: 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 proper code selection. Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care. Prepare and conduct 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), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes. Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. 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. 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. 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. Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patients stay. Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues. Work Schedule: Full time, Monday – Friday, 8:00am – 4:30pm Telework: Regular telework, 6 days/pay period. 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). 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. 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: BASIC REQUIREMENTS: The following are the basic requirements and qualifications for this position: United States Citizenship English Language Proficiency Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy and physiology, and introduction to health records). TRANSCRIPTS REQUIRED. OR Experience/Education Combination: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience: (a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. TRANSCRIPTS REQUIRED. QUALIFICATIONS: In addition to the basic requirements above the following is the amount of experience required to qualify for this position at the GS-9 grade level. Qualifications – Specialized Experience: Must possess at least one full year of experience as a MRT Clinical Documentation Improvement Specialist (CDIS) equivalent to the next lower level (GS-8) which demonstrates that CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met. In addition to the experience above, the candidate must demonstrate the following KSAs: (1). Knowledge of coding and documentation concepts, guidelines, and clinical terminology; (2). Ability to interpret and analyze all information in a patients health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the heath record; (3). Knowledge of anatomy and physiology, pathophysiology, and pharmacology; (4). Ability to establish and maintain strong verbal and written communication with providers; (5). Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines; (6). Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators. (7). Knowledge of severity of illness and risk of mortality indicators; and (8). Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature. 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. Note: Evidence of experience, must be supported by detailed documentation of duties performed in positions held. Please provide such documentation on your application or resume. Also, please provide work experience information such as hours per week and starting/ending dates of employment (month and year format) to establish one (1) full year of experience. The requirement for this proof is specified in the “How to Apply” section of this announcement. To be credible, experience must be documented in the application and verifiable through employment references and/or other means. Your resume must support your answers in the occupational questionnaire. References: VA Handbook 5005/79, Part II, Appendix G35, Medical Record Technician Qualification Standards, 9/5/2014. This can be found in the local Human Resources Office. The 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: 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 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. 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 an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.