Medical Records Technician (CDIS-Inpatient)
Company: Veterans Affairs, Veterans Health Administration
Location: Houston
Posted on: May 28, 2023
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Job Description:
Summary The Medical Record Technician (MRT) (Clinical
Documentation Improvement Specialist (CDIS) Inpatient) position is
located in the Health Information Management Section (HIMS) of the
Health Administration Section at the Michael E. DeBakey VA Medical
Center. MRT CDISs must be able to perform all duties of a MRT
(Coder-Inpatient). MRT CDISs serve as the liaison between health
information management and clinical staff. Responsibilities Reviews
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. 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. 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. 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. 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. Collaboratively works with the professional clinical
staff and provides support and education on documentation issues.
Assists in the development of guidelines for data compatibility,
consistency, and monitoring for compliance to improve the quality
for clinical, financial, and administrative data to ensure that all
information is fully documented and supported. Such efforts are
conducted to ensure the accuracy of billing denials and prevention
against fraud and abuse and to optimize the medical center's
authorized reimbursement for utilization of resources provided. As
a technical expert in health record documentation matters, 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.
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. Participates in
clinical rounds and may, where appropriate, offer information on
documentation, coding rules and reimbursement issues. The
documentation specialist is a member of the healthcare team, and as
such, shall assist all clinical providers with ICD, CPT and DRG
methodologies so that documentation will more accurately reflect
the occurrence of the encounter. 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. Work Schedule: Monday - Friday,
7:00am - 3:30pm, 7:30am - 4:00pm, or 8:00am - 4:30pm Telework:
Available Virtual: This is not a virtual position. Functional
Statement #: 000000 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 BASIC REQUIREMENTS:
1. United States Citizenship. Non-citizens may only be appointed
when it is not possible to recruit qualified citizens in accordance
with VA Handbook 5005, Part II, Chapter 3, Section A, paragraph
3.g. 2. Experience and Education. (A) 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. You must
demonstrate the experience on your resume with hours worked per
week to receive credit. OR (B) 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); You must submit a copy of your
transcript(s) showing award of associate's degree to receive
credit. OR (C) 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; You
must submit a copy of your transcript(s) showing award of
certificate or completion of program to receive credit. OR (D)
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:(i) 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. You must demonstrate the experience on your
resume with hours worked per week to receive credit AND submit a
copy of your transcript(s) showing completion of one year of course
with 6 semester hours of health information technology courses to
receive credit. (ii)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). You must demonstrate the experience on
your resume with hours worked per week to receive credit AND submit
a copy of your transcript(s) showing 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 to receive
credit. 3. Certification. You must submit a copy of your
certificate from AHIMA or AAPC to receive credit. 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. Current
apprentice/associate level certifications include: Certified Coding
Associate (CCA), Certified Professional Coder-Apprentice (CPC-A)
and Certified Outpatient Coding-Apprentice (COC-A). (2) Mastery
Level Certification through AHIMA or AAPC. 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). (3)
Clinical Documentation Improvement Certification through AHIMA or
ACDIS. Current Clinical Documentation Improvement Certifications
include: Clinical Documentation Improvement Practitioner (CDIP) and
Certified Clinical Documentation Specialist (CCDS). 4.
Grandfathering Provision. 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). 5.
English Language Proficiency. Candidates must be proficient in
spoken and written English to be appointed as authorized by 38
U.S.C. 7403(f). See Education section for Grade Determination and
continued Qualification information. Education GRADE DETERMINATION.
In addition to meeting the above Basic Requirements, you must also
meet the Grade Determination criteria below: Medical Records
Technician (Clinical Documentation Improvement Specialist
(CDIS-Inpatient)), GS-09 (a) Experience. Candidates must have: One
year of creditable experience equivalent to the journey grade level
of a MRT (Coder-Inpatient); To receive credit, you must demonstrate
work experience through job duties and list hours worked per week
for all jobs listed in your resume. 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); You must submit a copy
of your transcript(s) showing award of associate's degree to
receive credit AND you must demonstrate work experience through job
duties and list hours worked per week for all jobs listed in your
resume. OR, Mastery level certification through AHIMA or AAPC and
two years of experience in clinical documentation improvement; You
must submit an unexpired copy of your certificate from AHIMA or
AAPC AND you must demonstrate work experience through job duties
and list hours worked per week for all jobs listed in your resume
to receive credit. NOTE: 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). OR, Clinical
experience such as RN, M.D., or DO, and one year of experience in
clinical documentation improvement. To receive credit, you must
demonstrate work experience through job duties and list hours
worked per week for all jobs listed in your resume. (b)
Certification. Employees at this level must have either a mastery
level certification or a clinical documentation improvement
certification. You must submit an unexpired copy of your
certificate from AHIMA or AAPC to receive credit. NOTE: 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). Current Clinical Documentation Improvement Certifications
include: Clinical Documentation Improvement Practitioner (CDIP) and
Certified Clinical Documentation Specialist (CCDS). (c)
Demonstrated Knowledge, Skills, and Abilities (KSA). In addition to
the requirements above, candidates must demonstrate all the
following KSAs in their resumes: Knowledge of coding and
documentation concepts, guidelines, and clinical terminology.
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. Ability to collect and analyze
data and present results in various formats, which may include
presenting reports to various organizational levels. Ability to
establish and maintain strong verbal and written communication with
providers. Knowledge of regulations that define healthcare
documentation requirements, including The Joint Commission, CMS,
and VA guidelines. 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. Knowledge of
severity of illness, risk of mortality, and complexity of care.
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: Clinical knowledge (anatomy and physiology,
pathophysiology, and pharmacology) Applied knowledge of
documentation impact on reimbursement to include VERA funding
through the Allocation Resource Center (ARC) and third party payer
requirement References: VA Handbook 5005/122, Part II Appendix G77,
Medical Records Technician (Coder), Qualification Standard dated
December 10, 2019. The full performance level of this vacancy is
GS-09. Physical Requirements: Must be compliant with the following
physical standards and environmental factors: Light lifting of 15
pounds; Moderate carrying, 15-44 pounds; Both hands are required;
and Working closely with others. 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. 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.
Keywords: Veterans Affairs, Veterans Health Administration, Houston , Medical Records Technician (CDIS-Inpatient), Professions , Houston, Texas
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