This job opportunity announcement (JOA) will be used to fill one (1) Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient), GS-0675-09 vacancy at the Memphis, TN Veteran Affairs Medical Center (VAMC), with Business Office Service.

Duties

This position is located in the Health Information Management (HIM) section of the Business Office at the Lt. Col. Luke Weathers, Jr. VA Medical Center. Duties and functions of the Medical Records Technician - Clinical Documentation Improvement Specialist (CDIS) - Outpatient include, but are not limited to the following: Responsible for reviewing the overall quality and completeness of clinical documentation. Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education. 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. Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the Program and Management Analyst aka VERA coordinator and coordinate provider documentation education with the VERA coordinator. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the (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. 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. 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 health record. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation. Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate. Collaboratively works with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. 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. The CDIS is expected to strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines, e.g. upcoding, unbundling, or down coding. Work Schedule: Full time, Monday - Friday, 7:00 am - 3:30 pm; 9:00 am to 5:30 pm. Compressed/Flexible: Available Virtual: No Telework Eligible: VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process. May be authorized for highly qualified candidates Work Location: Lt. Col. Luke Weathers, Jr. VA Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104 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. English Language Proficiency. Must be proficient in spoken and written English. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. 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 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. 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. DEFINITIONS. a. Journey Level. The full performance level for the MRT (Coder) assignment is GS-8. b. 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). c. Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means. d. 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). e. 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). In addition to the basic requirements, the below qualification requirements must be met at the grade in which you are applying. Grade Determinations: GS-9 (a.) Experience and/or Education: To Qualify for the GS-09 CDIS, you must have one of the following education and or experience. (1.) One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient); OR, (2.) 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, (3.) Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR, (4.) Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. (b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. See definitions d. and e. above. (c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology. 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. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Ability to establish and maintain strong verbal and written communication with providers. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. 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. 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. 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 Physical Requirements: The majority of work is performed in an office setting, primarily while seated. The position requires some standing, ambulation, bending and carrying of items such as training manuals. In addition, there can be increased stress due to the intensity of a patient/customer complaint or concern.

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 Memphis VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104 US
• Name: Judith Castro
• Phone: 4078406953
• Email: [email protected]