This position is located in the Health Information Management (HIM) section at the New Mexico VA Health Care System (NMVAHCS). Medical Record Technicians (MRT) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Duties

Inpatient Clinical Documentation Improvement Specialist (CDIS) must be able to perform all duties of a MRT (Coder-Inpatient). CDISs serve as the liaison between health information management and clinical staff. 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. 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. Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity. Develop and/or update medical center policy pertaining to clinical documentation. Serve as a technical expert in health record content and documentation requirements. Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. Review appropriateness of and responses to queries through review of query reports. Perform 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 groups and leadership. Obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. 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. 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. Provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures in order to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting. Work Schedule: Monday to Friday 7:30 a.m.- 4:00 p.m. or 8:00 a.m.- 4:30 p.m. Telework: Available Virtual: This is not a virtual position. Functional Statement #: 00000 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. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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 or 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. 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). 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: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)), GS-9 Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-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. 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: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii. 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. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. iv. Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. 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. vii. Knowledge of severity of illness, risk of mortality, and complexity of care. viii. 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, Part II, Appendix G57 Medical Records Technician (Coder) Qualification Standard, GS-0675. The full performance level of this vacancy is GS-09. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

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 Raymond G Murphy Department of Veterans Affairs Medical Center 1501 San Pedro Drive, Southeast Albuquerque, NM 87108 US
• Name: Francisco Olmedo
• Phone: (562) 256-2012
• Email: [email protected]