Medical Records Technician (CODER) - CDIS

Employer
USAJobs
Location
Washington, D.C
Posted
Oct 15, 2019
Closes
Oct 17, 2019
Hours
Full Time
Duties

Summary

The Medical Record Technician - Coder, CDIS position is located in the Health Information Management (HIM) section of the Washington VA Medical Center. The incumbent will be responsible for abstracting medical record data & assigning codes using current clinical classification systems appropriate for the type of care provided.
Learn more about this agency

Responsibilities

NOTE: If you are a current/permanent VA employee, please apply to the Internal Job Announcement, VIN: 10613888 at the following link:
https://www.usajobs.gov/GetJob/ViewDetails/546782200

Duties of the position includes, but not limited to:
  • Develops and/or updates medical center policy memoranda pertaining to documentation improvement;
  • Serves as technical expert in health record content and documentation requirement;
  • 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;
  • Obtains appropriate corrective action plans from responsible clinical services directors, when necessary, and recommends improvements or changes in documentation;
  • Adheres 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;
  • 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;
  • Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS);
  • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC;
  • 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;
  • Periodically works and trains clinical staff on documentation improvement opportunities at the VA Medical Center or any of our five community-based outpatient clinics (CBOCs) located in Ft. Belvoir, VA; Southeast Washington, DC; and in Greenbelt, Charlotte Hall and Camp Springs, MD.
Work Schedule: Full-Time, Monday through Friday, 8:00 am to 4:30 pm
Financial Disclosure Report: Not required
Relocation/Recruitment Incentives/Allowances: Not authorized
Relocation/Recruitment Incentives/Allowances: Not authorized
Telework: Eligibility dependent upon Supervisory approval

Travel Required

Occasional travel - You may be expected to travel for this position. Travel to surrounding CBOCs for training purposes may be required as needed.

Supervisory status
No

Promotion Potential
None

Requirements

Conditions 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


Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 10/15/2019.

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 must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
Experience and Education:

(1) 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,
(2) 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 & physiology, and introduction to health records). OR,
(3) 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 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 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.

Grade Determinations:

GS-9 Medical Records Technician (Coder) (CDIS) - Experience. In addition to meeting the basic requirements, you must have one year of experience equivalent to the next lower grade level (GS-8). Experience is only creditable if it is either directly related to the position or in a related field at the next lower grade level. Experience satisfying this requirement must be active practice, which is paid/non-paid employment as an MRT in the parenthetical title (Coder) Clinical Documentation Improvement Specialist (CDIS). Experience includes but is not limited to: Analyzing and abstracting medical record data and assigning codes using clinical classification systems; Providing education related to coding and documentation; Performing either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties; (Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services); consulting with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record; abstracting and sequencing codes into encoder software to obtain correct diagnosis-related group (DRG); Entering and correcting information that has been rejected, when necessary; Correcting any identifying data errors or inconsistencies.

Demonstrated KSAs: In addition to the experience above, you 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 patient's 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 or may focus on teaching techniques for the improvement of clinical documentation issues.

Grandfathering Provision. All persons employed in VHA as a MRT on the effective date of the qualification standard (September 5, 2014) are considered to have met all qualification requirements for the title, series and grade held, including positive education that is part of the basic requirements of the occupation.

Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time workweek. For example, a MRT would receive 1 week of full-time credit for each 2 weeks of half-time work.

References: VA Handbook 5005, Part II, Appendix G35 dated September 5, 2014

The full performance level of this vacancy is GS-9.

Physical Demands: The physical demands of the work are generally minor. The work is primarily sedentary (6- 8 hrs.) although, there is some walking (1 hr.), bending (1hr), and carrying of bulky files (1- 10 lbs.) and some extended periods of standing (2 hrs.).

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.

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.

NOTE: The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and salary at which the candidate will be placed. For internal selectees eligible for promotion, the board will recommend grade and HR will determine step in accordance with policy.

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 clearance

Security clearance
Other

Drug test required
No

Required Documents

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

  • Form 10-2850c is required
  • Resume


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 . This form is due at the time of application.

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 (Schedule A)
  • Disability Letter (VA)
  • Certification if applicable
  • Form 10-2850c is required
  • Resume
  • Separation Notice (RIF)
  • 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.

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