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Medical Records Technician (Clinical Documentation Improvement Specialist-Outpatient/Inpatient)

  • Full-Time
  • San Antonio, TX
  • US Department Of Veterans Affairs
  • Posted 3 years ago – Accepting applications
Job Description
    DutiesSummary

    This position is in the Health Information Management (HIM) section at the Audie L. Murphy VA Medical Center. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

    Responsibilities

    • Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as Functional Statement Medical Records Technician (Coder) CDIS, well as the principles and practices of health services and the organizational structure to ensure proper code selection;
    • Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding;
    • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services;
    • 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;
    • 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;
    • 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; and
    • 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).

    Work Schedule: Monday-Friday, 0800-1630 CST
    Financial Disclosure Report: Not required

    Travel Required

    Not required

    Supervisory status

    No

    Promotion Potential

    None

  • Job family (Series)

    0675 Medical Records Technician

    Similar jobs
    • Coders, Health Information
    • Health Information Coders
    • Health Information Technicians
    • Medical Records And Health Information Technicians
    • Medical Records Specialists
    • Medical Records Technicians

  • Requirements

    RequirementsConditions 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
    • 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
    QualificationsApplicants 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:
    • 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.
    • Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
    • 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.
    • Loss of Credential. 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. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.
    • 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).

    Preferred Experience: Experience with the responsible for the development and implementation of active training/education programs and serve as a technical expert in health record content and documentation requirements.

    Grade Determinations for MRT (Coder-Outpatient and Inpatient)

    GS-09:Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);
    OR,
    Education and Experience: 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,
    Certificate and Experience: Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
    OR,
    Experience: 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.
    AND
    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 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 ICDCM and PCS, CPT, and HCPCS. They must also possess 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, complexity of care for inpatients, and 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 for outpatients.
    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.

    References: VA Handbook 5005/122 December 10, 2019 PART II APPENDIX G57

    The full performance level of this vacancy is GS-09.

    Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds. 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.

    NOTE: If your school has changed names, or is no longer in existence, you must provide this information in your application.

    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 clearanceSecurity clearance

    Other

    Drug test required

    No

    Position sensitivity and risk

    Non-sensitive (NS)/Low Risk

    Trust determination process

    Suitability/Fitness, Credentialing

  • Required Documents

    Required Documents

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

    • VA Form 10-2850C Application for Associated Health Occupations (Must be within the last 90 days)
    • Professional Certification
    • 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.

    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)
    • License
    • OF-306
    • VA Form 10-2850C Application for Associated Health Occupations (Must be within the last 90 days)
    • PCS Orders
    • Performance Appraisal
    • Professional Certification
    • Proof of Enrollment
    • Proof of Marriage Status
    • 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.

  • Benefits

    Benefits

    A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits.

    Review our benefits

    Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.


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    U.S. citizens, nationals or those who owe allegiance to the U.S.

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