Duties

Summary

This position is located in the Health Information Management (HIM) section at the Hampton VA Medical Center. The Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient) is 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.

**This is NOT a Virtual Position**
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Responsibilities

Duties include but are 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 proper code selection.
• Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care.
• 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, ensuring documentation supports the codes selected t the highest degree of specificity.
• Adheres to accepted coding practices, guidelines and conventions to ensure ethical, accurate, and complete coding.

Work Schedule: Monday - Friday 7:30AM - 4:00PM OR 8:00AM - 4:30PM
Financial Disclosure Report: Not required

Travel Required

Not required

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

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:

• 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: Proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience & Education: Experience. 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & 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 & physiology, medical coding, & 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 & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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 & education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience: (a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, & 1 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 & 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, & health record techniques & procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

Grade Determinations:

GS-09 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 Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (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.

Master Level Certification: Certification 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 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, & 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).

You must also demonstrate the following KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
2. Knowledge of anatomy & physiology, pathophysiology, and pharmacology to interpret & analyze all information in a patient's health record, including laboratory & other test results to identify opportunities for more precise and/or complete documentation in the health record.
3. Ability to collect & analyze data & present results in various formats, which may include presenting reports to various organizational levels.
4. Ability to establish & maintain strong verbal & written communications with providers.
5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, & VA guidelines.
6. Extensive knowledge of coding rules & regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
7. Knowledge of severity of illness, risk of mortality, complexity of care.
8. Knowledge of training methods & 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.

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).

References: VA Handbook 5005/122, Part II, Appendix G57 MEDICAL RECORD TECHNICIAN Qualification Standard, dated December 10, 2019. This can be found in the local Human Resources Office.

Physical Requirements: Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; both hands required; hearing (aid permitted); sitting for up to 8 hours; repetitive motions for computer data entry.

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. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. 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.

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.

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

Position sensitivity and risk
Non-sensitive (NS)/Low Risk

Trust determination process
Suitability/Fitness

Required Documents

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

• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action

VA Form 10-2850c Application for Associated Health Occupations can be found at: https://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf .

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
• Other (1)
• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action
• Transcript

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.