This position is located in the Health Information Management (HIM) section at the VA Ann Arbor Healthcare System. MRTs (Coder) 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, multi-specialty clinics, and specialty centers. Supervisory MRT CDIS must be able to perform all duties of a MRT Coder CDIS (inpatient and outpatient) and MRT Coder Auditor.

Duties

Major duties for this position include, but is not limited to: 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 proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). 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 (in inpatient and outpatient settings) used to classify patients under the 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 coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs. 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. Insures 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 health record. SUPERVISORY EXPERIENCE 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. Keeps employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concerns. Schedules the sequence of work and operations on a weekly, monthly and quarterly basis to assure even workflow and distribution, expeditious handling of priorities and the meeting of deadlines. Revises schedules/assignments to meet changes in workload considering peak loads, availability of manpower and time limits. Makes changes in organization and assignment of duties to provide improvements, promote job satisfaction and increase productivity. Prepares workload and production reports; reports on operations and problems encountered; and presents proposed requests for resource needs based on experience, anticipated staffing, equipment and space. Makes assignments that are equitable among employees. Formulates and issues written instructions and procedures and special instructions for non-routine or complex assignments or to clarify published guides. Assignments are made based on selective considerations such as difficulty and requirements of assignment, availability, capability and grades of employees, and availability of other resources. Reviews compliance monitors with staff and identifies training needs; Audits reviews to ensure appropriateness and compliance with established policies; Provides guidance to various levels of staff to promote consistency in practice Keeps abreast of all regulations and guidelines governing the CDI/VERA audit program, ensuring staff supervised are educated as needed. Ensures that regulatory guidelines and current coding conventions are followed. Coordinates with other Service representatives on matters concerning health record documentation and coding, as well as changes and challenges that may have an impact on other Units or Services. Work Schedule: Monday - Friday 8:00 AM - 4:30 PM Telework: Available Virtual: This is not a virtual position. Functional Statement #: 92049 Relocation/Recruitment Incentives: 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. Must be proficient in written and spoken English. 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 December 10, 2019 VA Handbook 5005/122 PART II APPENDIX G57 II-G57-3 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). Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1)Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2)Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. (3)MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (4)MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation. (5)Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. Grade Determinations: Supervisory Medical Records Technician (Coder), GS-10: (a) Supervisory coder assignments can be established for any of the coder subspecialties (outpatient, inpatient, outpatient and inpatient combined). The subspecialty will be reflected in the title, e.g., Supervisory MRT (Coder-Outpatient). (b) Experience. One year of creditable experience equivalent to the next lower grade level. (c)Demonstrated KSAs. In addition to the experience above, the employee must demonstrate all of the following KSAs: (1) 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; (2) Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined); (3) Ability to provide or coordinate staff development and training; (4) Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers; and (5) Ability to collect and analyze data, identify trends, and present results in various formats. c) Certification. Employees at this level must have a mastery level certification. 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). d) 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. References: VA Handbook 5005, Part II, Appendix G57.The full performance level of this vacancy is GS-10. Physical Requirements: The work is primarily sedentary. However, there can be some walking, standing, bending, and carrying of light items such as papers, books, files, etc.

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 Ann Arbor VA Medical Center 2215 Fuller Road Ann Arbor, MI 48105 US
• Name: Tiffani Battle
• Phone: (512) 592-8461
• Email: [email protected]