This position is located in the Health Information Management (HIMS) section at the Orlando VA Medical Center. The Medical records Technician (CDIS) is responsible for health record review for ambiguous, conflicting, incomplete or nonspecific provider documentation and to provide education to healthcare providers on documentation integrity and improvement.

Duties

CDISs serve as the liaison between health information management and clinical staff. They are responsible for facilitating improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify 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. They recommend changes and/or update medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. They review 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. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. They monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education. They are responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met. They provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. They apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and complete significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting. These are also applied to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. This job opportunity announcement may be used to fill additional vacancies in similar positions within corporate Orlando. This includes the same grade level and occupational series, but may be used for a different service or location. Work Schedule: Monday - Friday 8:00am-4:30pm. Compressed/Flexible:Not available Telework: Available Virtual: This is a virtual position. Position Title/Functional Statement #:Medical Records Technician-CDIS-Inpatient/FS#80537F. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required.

Requirements

Qualifications

This vacancy is open to current permanent employees of the Veterans health Administration (VA Nation-wide) ONLY. 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. Grade Determinations: Medical Records Technician (CDIS-Inpatient), GS-9: (a) Experience. One year of creditable experience equivalent to the journey grade level GS-8 of a MRT (Coder-Inpatient). (b) Certification. Employees at this level must have a mastery level certification through AHIMA or AAPC. (c) Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Outpatient CDISs must be able to perform all duties of a MRT (Coder-Outpatient). CDISs serve as the liaison between health information management and clinical staff. They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload, and resource allocations. They review documentation and facilitate modifications to the health record to ensure accurate complexity of care and utilization of resources. They identify 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. They recommend changes and/or updates to medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. They are responsible for performing reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate leadership and groups. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. They monitor trends in the industry and/or changes in regulations that could or should impact coding and documentation practices and identify who may require education. They are responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met. They provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques including accurate and ethical documentation practices. They apply applicable coding conventions and guidelines to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. (d) Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience above, the candidate must demonstrate all of the following KSAs: REFER TO THE "How You Will Be Evaluated Section" BELOW: 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). d. Grandfathering Provision. The following is the standard grandfathering policy for all Title 38 Hybrid qualification standards. Some of these provisions may not apply to this occupation. Please carefully review the qualification standard to determine the specific education and/or licensure/certification/ registration requirements that apply to this occupation. All persons employed in VHA in this occupation 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 licensure/certification/registration that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements required in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees in an occupation that does not require a licensure/certification/registration, may be reassigned, promoted, or demoted within the occupation. Such employees in an occupation that requires a licensure/certification/registration, may be reassigned, promoted up to and including the full performance (journey) level, or demoted within the occupation, but may not be promoted beyond the journey level or placed in supervisory or managerial positions. Such employees in an occupation that requires a licensure/certification/registration only at higher grade levels must meet the licensure/certification/registration requirement before they can be promoted to those higher grade levels. Employees 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. Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation. If an employee who was retained in an occupation listed in 38 U.S.C. § 7401(3) under this provision leaves that occupation, the employee loses protected status and must meet the full VA qualification standard requirements in effect at the time of reentry to the occupation. e. Physical Requirements. See VA Directive and Handbook 5019. f. English Language Proficiency. Medical Instrument Technicians must be proficient in spoken and written English in accordance with chapter 2, section D, paragraph 5a, this part. References: VA Handbook 5005/122 Part II, Appendix G57 The full performance level of this vacancy is GS-9. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9 to GS-9.

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 Orlando VA Medical Center 13800 Veterans Way Orlando, FL 32827 US
• Name: Michael Brown
• Phone: 407-405-6894
• Email: [email protected]