This position is located in the Health Information Management (HIM) Section at the Tuscaloosa VAMC. The Medical Records Technician Clinical Documentation Improvement Specialist (Coder/CDIS) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Duties

Duties to include but not limited to: Coder/CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Recommend and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. 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. Responsible to obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere 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. Work Schedule: Monday-Friday 8:00 am to 4:30 pm Financial Discloser Report: Not required

Requirements

• 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, 08/17/2023. 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. Certification. 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. Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Inpatient/Outpatient) GS-8 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. Grade Determinations: In addition to the certification and experience above, the candidate must demonstrate the following KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology. 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. 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 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. 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. 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, Part II, Appendix G57

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.

Contacts

• Address Tuscaloosa VA Medical Center 3701 Loop Road East Tuscaloosa, AL 35404 US
• Name: James Brinson
• Email: [email protected]