The Oklahoma City VA Healthcare System is currently recruiting for one Supervisory Medical Records Technician-Clinical Documentation Improvement Specialist, Inpatient and Outpatient, to be part of Health Administration Service.

Duties

Supervisory Medical Records Technician-Clinical Documentation Improvement Specialists are responsible for the supervision, administrative management, and direction of CDIS staff at the facility level. Supervisory Medical Records Technician-Clinical Documentation Improvement Specialists must be able to perform all duties of a Medical Records Technician-Clinical Documentation Improvement Specialist. Clinical Documentation Improvement Specialists serve as the liaison between health information management and clinical staff. Major duties and responsibilities include, but are not limited to the following: 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 clinical documentation supports 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. Adheres to accepted CDI practices, guidelines and conventions when reviewing health record documentation and providing feedback and training to clinical staff. Prepares and conducts 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. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, SharePoint, and Access; competent in use of the health record applications (VistA, CPRS, and Cerner) 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. Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues. 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. Develops performance standards and conducts performance evaluations for subordinate staff. Interviews new employees, recommends selection, and carries out training and development of reassignments, awards or disciplinary action. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill and ability to perform the full range of routine and non-routine responsibilities required. Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines. Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources. Reviews compliance monitors with subordinates and identifies training needs. Train others on the encoder product suite and other relevant products related to CDI. Utilizes these systems on an on-going basis to perform core CDI duties and audits. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs on unit operations, CDI, abstracting, and use of an electronic health record. Work Schedule: Monday - Friday 8:00 am to 4:30 pm Compressed/Flexible:Not available Telework: Not available Virtual: Not available Functional Statement #: 56363-0/Supervisory Medical Records Technician (CDIS) Relocation/Recruitment Incentives: 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. Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder). Basic Requirements: Citizenship. Be a citizen of the United States. English Proficiency: Must be proficient in spoken and written English. Experience and Education: 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, 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; 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: (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: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). 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. 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. Grade Determinations: Supervisory Medical Records Technician-Clinical Documentation Improvement Specialist, GS-10. Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to perform a full range of supervisory duties, to include recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure duties are completed in an accurate and timely fashion; Advanced knowledge of current coding classification systems such as International Classification of Diseases, Current Procedural Terminology, and Healthcare Common Procedure Coding System for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined); Advanced knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related Groups structure, Present On Admission indicators, 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; Skill in training methods and teaching skills sufficient to conduct continuing education for staff development and training on topics related to clinical documentation integrity and improvement issues; Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers; and Ability to collect and analyze data, identify trends, and present results in various formats. References: VA Handbook 5005/122, Part II, Appendix G57 The full performance level of this vacancy is GS-10. Physical Requirements: Must be able to meet the physical demands of this position and be able to communicate both in written and verbal means. Must be able to use a computer and sit at a computer desk for prolonged periods of time throughout the day.

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 Oklahoma City VA Health Care System 921 Northeast 13th Street Oklahoma City, OK 73104 US
• Name: Jason Luper
• Phone: (405) 421-2158
• Email: [email protected]