Medical Records Technician - (Clinical Documentation Improvement Specialist (CDIS - Inpatient))

Employer
USAJobs
Location
Wallops Island, Virginia
Posted
Jan 24, 2023
Closes
Jan 28, 2023
Hours
Full Time
Duties

The duties of the Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Inpatient)) in the Business Office include but not limited to:
  • Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house.
  • 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 inpatient 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, ensuring documentation supports the codes selected to the highest degree of specificity.
  • Adheres to accepted coding practices, guidelines, and conventions 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. Ensures 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 needs.
  • 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. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. 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.
  • Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
  • Develops 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) 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.
Work Schedule: Monday - Friday, 7:30am-4:00pm/8:00am-4:30pm
Telework: This is a remote position.
Virtual: This is not a virtual position.
Functional Statement #: 598-00195-F
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.
  • Must pass pre-employment physical examination.
  • 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

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. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
  • Experience and Education:
    • (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 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 ACDIS.
    • NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.
Grade Determinations:
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Inpatient)), GS-9
Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-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.
Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification as per the below:
    Master Level Certification: This is considered a higher-level health information management or coding certification and is limited to those 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 & are not acceptable for qualifications. Certification titles may change & 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 Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Cordera (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, & 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) & Certified Clinical Documentation Specialist (CCDS).
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 in order 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 ICD CM and PCS. They must also possess a 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, and complexity of care.
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.

Preferred Experience: None.

References: VA Handbook 5005/122, Part II Appendix G57, MEDICAL RECORDS TECHNICIAN (CODER) Qualification Standard. This can be found in the local Human Resources Office.

The actual grade at which an applicant may be selected for 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

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. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. 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.

Physical Requirements: Light lifting (under 15 pounds), use of fingers, both hands required, both eyes required, ability to distinguish basic colors, ability to distinguish shades of colors, multiple posture for 8 hours a day. (See VA Directive and Handbook 5019, Employee Occupational Health Services).

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 to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application .