Medical Records Technician (CDIS Inpatient/Outpatient)

Description:

This position is located in the Health Information Management Section of the Medical Administration Service at VAMC West Palm Beach, Florida. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

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 :

• 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).
• Experience and Education
  • One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
    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 Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (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. 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. 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).
  • Grade Determination: One year equivalent to the GS-8 level that demonstrates the KSAs listed below.
  • 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 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.

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).

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

The full performance level of this vacancy is GS-9.

Physical Requirements: See VA Directive and Handbook 5019 , Employee Occupational Health Service.

The work is primarily sedentary with long periods of sitting at a desk, working with computers daily. Some work may require walking in offices and similar areas for meetings. Work may also require walking and standing in conjunction with travel to and attendance at meetings and conferences away from the worksite. The work does not require any special physical effort.