Medical Records Technician Clinical Documentation Improvement Specialist (In/Patient/Out-Patient)

Description:

Medical Records Technician Clinical Documentation Improvement Specialist (CDIS In/Out-Patient) position is in support of the Health Information Management Section (HIMS) of the Business Office Service Line at the VA Connecticut Healthcare System.

This remote option for this position will be assessed continuously, and if selected as a VA employee you may need to return to work to the nearest VA Office in the future, as determined by the agency policy.

Requirements:

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 :

a. Citizenship: Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)

b. 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 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).

c. 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

Grade Determination:
(a) 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;

NOTE: See above Paragraph 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.
(b) Certification : Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

NOTE: See paragraph above for a detailed definition of mastery level certification and 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.

Preferred Experience: LIS, Interface building, DI Instrument Manager, VISATA and Rule Writing.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/ .

The full performance level of this vacancy is a GS-09.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.
The work requires regular and recurring physical exertion such as standing for long periods of time, bending and stress and strain related to meeting the demands of the Medical Staff of an acute care hospital.