The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (CDIS - Outpatient). The Medical Records Technician (CDIS - Outpatient) will function in Health Information Management Service (HIMS) section of Patient Care Administrative Service (PCAS).
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: 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, 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: 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 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). 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). Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. Grade Determinations: In addition to the basic requirements listed above, the following criteria must be met when determining the grade of candidates. Experience: One year of creditable experience equivalent to the journey grade GS-8 level of a MRT (Coder-Outpatient); 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. AND Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. Mastery Level Certification: 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 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, and 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) and Certified Clinical Documentation Specialist. NOTE: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. AND 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. 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; 3. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. 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. Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS). 7. Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided. 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. Preferred Experience: 3-5 years of outpatient coding experience. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-9. Physical Requirements: The work is mostly sedentary. It typically requires sitting with sustained periods of concentration. There will be some walking, standing, bending, and carrying of relatively light objects. The position may also require stooping, reaching, lifting, pulling, and other moderate exertion or strain. Incumbent may occasionally have to walk some distance to a meeting.
Duties of the Medical Records Technician (CDIS-Outpatient) include but are not limited to: Responsible for performing reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate leadership and groups. Responsible for reviewing the overall quality and completeness of clinical documentation. Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education. 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 including admissions and discharges, observation, emergency department/urgent care, and clinic visits. 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, and ensuring documentation supports the codes selected to the highest degree of specificity. 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. 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. 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. Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary 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, 8:00am - 4:30pm Telework: May be available as determined by agency Virtual: This is not a virtual position. Functional Statement #: 91798A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized