This Medical Records Technician (Clinical Documentation Improvement Specialist, Inpatient) position is in Health Information Management services of the Business Office at the Boston VA Healthcare System, located at the West Roxbury location. This position is full-time at 40 hours per week.

Duties

Provides ongoing education to our providers and coding team members by conducting initial and extended-stay concurrent review on selected admissions and document findings identifying missed opportunities and clinical documentation improvements which will both enhance the quality of the health record documentation, maximize VERA and 3rd Party Collections. Identifies co-morbidities and complications and documents appropriately Queries the medical staff and other clinical caregivers as necessary via written/verbal communication to 2 obtain accurate and complete documentation. Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding, compliance issues, profiling concerns, and reimbursement changes according to VA regulations and policies. Furnishes guidelines and advice to the Health Information Management section and the medical staff; provides expertise and technical advice to the facility's Medical Record Review Committee, VERA committee and other program officials. Clinical Documentation Specialist applies unique knowledge in conducting studies to provide specialized data for medical center projects. Implements facility and regulatory policies and standards which impact health information management functions; implements and reviews in-service education and makes changes based on findings; review and recommends new reporting or documentation methods; maintains liaison with all HIMS campuses; prepares reports and position papers. 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. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under 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 coding information for the full spectrum of services provided by the VABHCS. 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 regulation 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 record. Responsible for assuring a coding compliance program has been developed, implemented and maintained as well as all policies and procedures are in place. Assures CPT and ICD codes, DRG's, APG's and modifiers can support clinical and physician medical documentation for proper and consistent data collection and reimbursement. Provides support and education on documentation issues and assists in development of guidelines for data compatibility, consistency and monitoring of compliance to improve the quality of clinical, financial and administrative data to ensure that all information is fully documented and supported. Work Schedule: Monday through Friday 7am to 3:30pm OR 7:30am to 4pm OR 8am to 4:30pm. Compressed/Flexible:Not Available. Telework: Available. Virtual: This is not a virtual position. Functional Statement #: F01480 Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized. Financial Disclosure Report: Not required.

Requirements

Qualifications

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: Must be proficient in both written and spoken English. 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. 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 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. 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. 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). Grade Determinations: Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-inpatient); 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. Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. 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 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. 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 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. vii. Knowledge of severity of illness, risk of mortality, and complexity of care. 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 Part II Appendix G57 Dated December 10, 2019. The full performance level of this vacancy is GS-9. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

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 VA Boston Healthcare System 940 Belmont Street Brockton, MA 02301 US
• Name: Nathaniel Lynch
• Phone: (401) 903-9708
• Email: [email protected]