This position is located in the Business Operations and Access Service at the Charlie Norwood VA Medical Center (CNVAMC). The Medical Records Technician (CDIS) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Duties

Duties include but are 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). Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM} staff. Ensures 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 by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital. 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. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis. Collaboratively works with 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. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided. As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc. 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. 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. 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 documentation specialist 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, DRG creep, etc. Selection of the principal diagnosis and principal procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set (UHDDS). Performs other duties as assigned by management. Work Schedule: Monday - Friday 8:00am to 4:30pm. Tour of duty subject to change based on agency needs. Telework: Ad-hoc telework available. Telework eligibility will be discussed during the interview process. Virtual: This is not a virtual position. Functional Statement #: PD000000 Relocation/Recruitment Incentives: Not Authorized. 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. Experience and/or 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. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. English Language Proficiency. Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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. Grandfathering Provision: 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). Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) GS-9 Experience. One year of creditable experience equivalent to the GS-08 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 RN, M.D., or DO, and one year of experience in clinical documentation improvement. NOTE: See paragraph 2g for a detailed definition of mastery level certification. OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Demonstrated Knowledge, Skills, and Abilities (KSAs). 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. Preferred Experience: Inpatient clinical documentation, improvement auditing, and querying. Department of Veterans Affairs Experience. References: VA HANDBOOK 5005/122 PART II APPENDIX G57, Medical Records Technician (Clinical documentation improvement specialist), GS-0675. The full performance level of this vacancy is GS-09. 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 Charlie Norwood VA Medical Center One Freedom Way Augusta, GA 30901 US
• Name: Chinaqua Winborn
• Phone: 334-590-5615
• Email: [email protected]