The Dayton, Ohio Veterans Affairs Medical Center (VAMC) Health Information Management (HIM) Section is recruiting for a well-qualified Medical Records Technician (MRT) (Clinical Documentation Improvement Specialist (CDIS-Outpatient)). They possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

Duties

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 facilitate improved overall quality, education, completeness, and accuracy of health record documentation. They review documentation and facilitate modifications to the health record. They identify opportunities for documentation improvement. They recommend changes and/or updates to medical center policy. They serve as a technical expert in their field. They query clinical staff to clarify documentation. They review queries through review of query reports. They perform reviews of the health record documentation. They obtain appropriate corrective action plans from clinical service directors and recommend improvements or changes. They adhere to established documentation requirements. They monitor trends in the industry and/or changes in regulations. They are responsible for the development and implementation of active training/education programs for all clinical staff to ensure the CDIS program objectives are met. They apply applicable coding conventions and guidelines to accurately reflect medical necessity and level of service or procedure performed. Duties include, but are not limited to: reviewing the overall quality and completeness of clinical documentation. applying 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. reviewing clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care. educating providers on documentation processes in the health record, and on the need for accurate and complete documentation in the health record. adhering to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code. reviewing VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator. monitoring ever-changing regulatory and policy requirements. assisting staff with documentation requirements; 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. searching the patient health record to find documentation justifying code assignment. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation. developing and conducting seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements. ensuring active intra-departmental training program is in place for the HIM staff. Determines and meets training needs of extra-departmental professional, para professional and non-professional personnel. facilitating improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation. ensuring the accuracy and completeness of clinical information. Identifying trends and/or opportunities to improve clinical documentation. working with the professional clinical staff and provides support and education on documentation issues. Assisting in the development of guidelines for data compatibility, consistency, and monitoring for compliance. providing advice and guidance in relation to documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc. analyzing situations or processes and recommends improvements or changes in documentation. May assist in writing coding protocol/policies. using medical data incidental to a variety of patient care and treatment activities. Reviews the health record and discusses the case with the clinical staff. Performs chart reviews for specific patient populations. striving 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, etc. Work Schedule: Monday through Friday, 0800- 1630 Telework: Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required

Requirements

Qualifications

BASIC REQUIREMENTS Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) 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. 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) GS-9 must have Mastery Level Certification through AHIMA or AAPC. 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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Grade Determinations: a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR, An associate 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. b) Demonstrated KSAs. In addition to the experience above, the employee 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 ICD, CPT, and HCPCS); Knowledge of 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; and 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 c) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement 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). Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist (CCDS). 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-08. The actual grade at which an applicant may be selected for this vacancy is GS-09. Physical Requirements: Work is mostly sedentary. However, there will be some periods of walking, bending, lifting or carrying of work-related items. Normal safety precautions and practices are required for working in a healthcare environment. This position requires emotional ability to deal effectively with multi-tasking and high volume of patient flow and competing demands.

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 Dayton VA Medical Center 4100 West Third Street Dayton, OH 45428 US
• Name: Sage Artemis
• Email: [email protected]