Medical Records Technician (Clinical Documentation Improvement Specialist- Outpatient/Inpatient)

Summary

This position is located in the Health Information Management (HIM) Section - under the Business Office - at the VA Medical Center - Atlanta - Ga. Medical Records Technicians (Coders) are skilled in classifying medical data from patient health records. These coding practitioners analyze patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

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 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 4 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) positions in the GS-0675 series in VHA must have either (1) - (2) - or (3) below: (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
• 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
• 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)
• 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
• For employees who do not meet all the basic requirements in this standard - but who met the qualifications applicable to the position at the time they were appointed to it
• Such employees may be reassigned - promoted up to and including the journey level (GS-08) - or changed to lower grade within the occupation - but will not be promoted beyond the journey level or placed in supervisory or managerial positions
• Grade Determinations: GS-9: Experience: One year of creditable experience equivalent to the journey 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 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 25 terminology
• ii
• 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
• 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 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
• vii
• 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
• 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
• Reference: VA Handbook 5005/122 - Part II Appendix G57
• For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• The full performance level of this vacancy is GS-09
• Physical Requirements: This work is primarily sedentary with long periods of sitting at a desk - working with computers daily.
  
  

Duties

• Major 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 to ensure proper code selection
• Reviewing clinical documentation and providing education to clinical staff on inpatient and outpatient episodes of care
• Preparing and conducting provider education on documentation processes in the health record to include the impact of documentation on coding - workload - quality measures - reimbursement - and funding
• Providing education to providers on the need for accurate and complete documentation in the health record - ensuring documentation supports the codes selected to the highest degree of specificity
• Adhering to accepted coding practices - guidelines - and conventions to ensure ethical - accurate - and complete coding
• Ensuring provider documentation is complete and supports the diagnoses and procedures coded
• Serves as the liaison between health information management and clinical staff and is responsible for facilitating the 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
• Reviews documentation and facilitate modifications to the health record to ensure accurate severity of illness - risk of mortality - complexity of care - and utilization of resources
• Responsible for reviewing the overall quality and completeness of clinical documentation
• Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective - ideally prior to coding and billing - review of outpatient encounters and extensive provider education
• Queries clinical staff to clarify ambiguous - conflicting - or incomplete documentation and reviews the appropriateness of and responses to queries through review of query reports
• Obtains appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices - when applicable
• Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator
• Ensures documentation supports codes based on guidelines specific to certain diagnoses - procedures - and other criteria 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
• Incumbent 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
• Work Schedule: Full-time - Monday-Friday - 8:00am-4:30pm
• (Subject to change based on agency need.) Telework: Ad-hoc telework as determined by the agency policy
• Virtual: This is not a virtual position
• Functional Statement #: 60956F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorize