The Cincinnati, OH VA Medical Center is recruiting for a full-time Medical Records Technician (Clinical Improvement Documentation Specialist) (CDIS).This position is located in the Health Information Management (HIM) section of the Patient Business Office. A 10% Recruitment Incentive is authorized for eligible candidates.

Duties

Major Duties:CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations.As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as coding and documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.Other duties and responsibilities include but are not limited to the following: Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. Performs reviews of the health record documentation; develops criteria, collects data, graphs, and analyzing results, creates reports, and communicates in writing and/or in person to the appropriate leadership and groups. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adheres to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy, and medical-legal requirements. Develops and implements active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met. Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary. May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation. Compiles, reviews, abstracts, analyzes, and interprets medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Reviews the health record and discusses the case with the clinical staff. Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record. Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation, lab results, diagnostic information, and treatment to ensure documentation reflects severity of illness, acuity, and resource consumption. Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues. The documentation specialist is a member of the healthcare team, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter. Other related duties, as assigned. Work Schedule: Monday-Friday 8:00 am- 4:30 pm Compressed/Flexible: This will be discussed during the Interview process. Telework: This will be discussed during the Interview process. Virtual: This is not a virtual position. Functional Statement #: 91917-A Relocation/Recruitment Incentives: A 10% Recruitment Incentive may be available for eligible candidates. Permanent Change of Station (PCS): 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. 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: 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. 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. For this GS-9 CDIS position, you must have either a mastery level certification or a clinical documentation improvement certification.NOTE: You must provide a current/active copy of your certification in your application packet in order to be considered. 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 Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Preferred Experience: N/A Grade Determination: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient), GS-9: One year of creditable experience equivalent to the GS-8 grade level of a MRT (Coder-Outpatient and Inpatient); OR 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 Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. And Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. 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 in order 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 CM and PCS. They must also possess a 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, and complexity of care. 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: See VA Handbook 5005, Part II, Appendix G57 Physical Requirements: Position is mostly sedentary. Work is performed in an office or alternate duty station setting with occasional visits to areas within the service as well as throughout the Medical Center. Work area is adequately lighted, heated and air conditioned. The normal risks and discomforts typical of an office and clerical work area are included. There are no unusual risks or safety hazards associated with this position.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Cincinnati VA Medical Center 3200 Vine Street Cincinnati, OH 45220 US
• Name: Kelly Webb
• Email: [email protected]