The Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS) position is located in the Health Information Management (HIM) section at the the Overton Brooks VA Medical Center in Shreveport, LA. The MRT (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Duties

If you are not a current, permanent VA employee or Federal employee from another agency, you should apply CBST-12414684-24-TM. Duties include but 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). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (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. 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. 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. 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 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. 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. 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. 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). Work Schedule: 8:00am - 4:30pm, Monday - Friday Telework: Available Virtual: This is not a virtual position. Functional Statement #: 667-00384-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

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: Candidates appointed to direct patient care positions must be proficient in both spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). Experience & 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 or successful completion of a course for medical technicians, hospital corpsmen, medical service specialists orhospital 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: Person hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either: 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. 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-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. NOTE: 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). 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. 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. 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). References: VA Handbook 5005/122 December 10, 2019 PART II APPENDIX G57 The full performance level of this vacancy is GS-8. Physical Demands: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, pulling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.

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 Overton Brooks VA Medical Center 510 East Stoner Avenue Shreveport, LA 71101 US
• Name: Theresa Morehart
• Phone: 501-522-4386
• Email: [email protected]