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Job Title: Medical Records Technician - Clinical Documentation Improvement Specialist-Outpatient and Inpatient
Company Name: Veterans Health Administration
Location: Wilkes Barre, PA
Position Type: Full-Time
Post Date: 05/19/2022
Expire Date: 07/07/2022
Job Categories: Accounting/Auditing, Agriculture, Forestry, & Fishing, Computers, Software, Healthcare, Other, Healthcare, Practitioner and Technician, Information Technology, Research & Development, Medical
Job Description
Medical Records Technician - Clinical Documentation Improvement Specialist-Outpatient and Inpatient
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 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. 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: Must have Certification through AHIMA, AAPC, or ACDIS. Acceptable certifications include: Certified Coding Associate (CCA), Certified Professional Coder-Apprentice (CPC-A), Certified Outpatient Coding-Apprentice (COC-A), 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 Certifications include: Clinical Documentation Improvement Practitioner (CDIP), and Certified Clinical Documentation Specialist. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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-Outpatient and Inpatient), GS-9 Experience. One year of creditable experience equivalent to the next lower grade level GS-8 level. Examples of experience are: select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records; independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties; directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record; abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered; review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature; query clinical staff with documentation requirements to support the coding process; enter and correct information that has been rejected, when necessary; correct any identified data errors or inconsistencies; ensure audit findings have been corrected and refiled; OR An associate's degree or higher 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), and three years of experience in clinical documentation improvement; OR A Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR I have clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement; AND 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. References: VA Handbook 5005/122, Part II, Appendix G57, Medical Records Technician (Coder) Qualification Standard Physical Requirements: Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files.
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Contact Information
Company Name: Veterans Health Administration
Website:https://www.usajobs.gov:443/GetJob/ViewDetails/654979900?utm_source=hbcuconnect&utm_medium=job_feed&utm_campaign=ar_vha_job_boards_feeds&utm_content=0675
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