OUR MISSION: To fulfill President Lincoln's promise - "To care for him who shall have borne the battle and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate care to Veterans?

Duties

VISN 12 is committed to fostering and sustaining an environment which celebrates diversity, provides equitable opportunities for employment and promotion, and supports inclusiveness in our culture. Together, we strive to create and maintain working and learning environments that promote professional growth and teamwork, and are inclusive, equitable and welcoming. We embrace our differences as individuals and unite as a team toward a common goal: to serve our nation's Veterans. This position is located in the Health Information Management (HIM) section at the William S. Middleton Memorial VA Hospital. Medical Records Technicians (Coders) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multispecialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Medical Records Technician Coder (CDIS) duties include: - Ensures clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. - Reviews documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. - Identifies opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. - Develops and/or update medical center policy pertaining to clinical documentation improvement. - Serves as a technical expert in health record content and documentation requirements. - Queries clinical staff to clarify ambiguous, conflicting, or incomplete documentation. - Reviews appropriateness of and response to queries through review of query reports. - Reviews health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership. - Obtains appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. - Adheres to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. - Monitors trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education. - Develops and implements active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for clinical staff to ensure the CDIS program objectives are met. - Applies applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures in order to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. - Performs other related duties as assigned. Work Schedule: M-F 8:00am to 4:30pm Compressed/Flexible: Telework: May be Authorized Virtual: This is not a virtual position. Functional Statement #: Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. The work does not require any special physical effort or ability. The work area is usually an adequately lighted, heated, and ventilated office or medical facility setting. The work environment involves everyday risks or discomforts that require normal safety precautions.

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 within 15 days of the closing date of this announcement,09/15/2023. BASIC REQUIREMENTS: The following are the basic requirements and qualifications for this position at the entry level at the GS-4 grade. Citizenship: Must be United States Citizen. English: Must be proficient in basic written and spoken English. Experience: At least one (1) year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records. OR, Education: An associate 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). (TRANSCRIPTS REQUIRED) OR, Completion of an AHIMA approved coding program: Completion of an AHIMA approved coding program or other intense coding training program of approximately one (1) 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. (CERTIFICATION REQUIRED) OR, Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following education/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 of 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 MRT Coder. Certification Requirement: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (CERTIFICATION REQUIRED) Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. GRADE REQUIREMENTS: In addition to the basic requirements above the following is the amount of experience, education and certification required to qualify for a Medical Records Technician (CDIS -Outpatient and Inpatient) at the GS-9 grade level. Experience: At least one (1) full year of creditable experience equivalent to the journey grade level (GS-8) of an MRT (Coder-Outpatient and Inpatient). OR, An associate degree or higher, and three years of experience in clinical documentation improvement and candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records. (TRANSCRIPTS REQUIRED) OR, Mastery level certification through AHIMA or AAPC AND two years of experience in clinical documentation improvement. OR, Clinical Experience: Experience such as RN, M.D., or DO, AND one year of experience in clinical documentation improvement. Certification Requirement: Applicants at this level must have either a mastery level certification or clinical documentation improvement certification as per the below: (a) 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 and are not acceptable for qualifications. Certification titles may change and 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 Cordera (COC), Certified Inpatient Coder (CIC). (b) 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 (CCDS). (CERTIFICATION REQUIRED) IN ADDITION TO REQUIRED EXPERIENCE, EDUCATION AND CERTIFICATION ABOVE, THE CANDIDATE MUST ALSO DEMONSTRATE THE FOLLOWING KSAs: (1) Knowledge of coding and documentation concepts, guidelines, and clinical terminology. (2) 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. (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 communications 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 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. (7) 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. (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. References: VA Handbook 5005/122, Part II, Appendix G57, Medical Record Technician (Coder) Qualification Standards, 12/10/2019. This can be found in the local Human Resources Office.

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.

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.

Contacts

• Address William S Middleton Memorial Veterans Hospital 2500 Overlook Terrace Madison, WI 53705 US
• Name: Matthew Acree
• Phone: (608)256-1901 X17488
• Email: [email protected]