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Medical Records Technician (Clinical Documentation Improvement Specialist -Outpatient and Inpatient)
Company: Veterans Affairs, Veterans Health Administration
Location: New Orleans, LA
Employment Type: Full-Time
Date Posted: 01/21/2021
Expire Date: 03/10/2021
Job Categories: Agriculture, Forestry, & Fishing, Computers, Software, Healthcare, Other, Healthcare, Practitioner and Technician, Information Technology, Research & Development, Medical, Environmental
Job Description
Medical Records Technician (Clinical Documentation Improvement Specialist -Outpatient and Inpatient)
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. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Experience and Education: (1) Experience. 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure and format of a health records.
(2) Education. An AA/AS 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 & physiology, medical coding, & introduction to health records);
(3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 year or more that included courses in anatomy & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & the sponsoring academic institution must have been accredited by a national U.S. Dept of Education accreditor, or comparable international accrediting authority at the time the program was completed;
Experience/Education Combination. Equivalent combinations of creditable experience & education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience:
(a)6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, & 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 6 months of experience provided the training program included courses in anatomy, physiology, & health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). 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 & meet the criteria). Preferred Experience: 3 years minimum coding experience in Inpatient/Outpatient setting. Extensive knowledge and skills in the use of different types of software applications which includes but are not limited to; word processing, spreadsheets & database software for data validation programs. 1 year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);at equipped me with the knowledge, skills & abilities to successfully perform the duties of this position. Grade Determinations: In addition to the basic requirements, the below qualification requirements must be met at the grade in which you are applying. GS-9: (a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);OR
An A.A 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.
(b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. Demonstrated KSAs:
i. Knowledge of coding and documentation concepts, guidelines, and clinical 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 & 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 & regulations, to include current clinical classification systems such as ICDCM & PCS, CPT, & HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, & 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, & level of E/M service provided for outpatients.
viii. Knowledge of training methods & 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. Master Level Certifications: Certified Coding Specialist, Certified Coding Specialist-Physician-based, Registered Health Information Technician, Registered Health Informatic Administrator, Certified Professional Coder, Certified Outpatient Cordera, Certified Inpatient Coder. Clinical Documentation Improvement Certification: This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists. The specific certification must certify mastery in clinical documentation. Certification titles may change, & 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 & Certified Clinical Documentation Specialist. References: VA Handbook 5005/122, Part II, Appendix G57, dated 12/10/2019 The full performance level of this vacancy is GS-9. The actual grade at which an applicant may be selected for this vacancy is a GS-9. Physical Requirements: Light carrying, under 15 pounds, use of fingers, walking 1-2 hours, standing 1-2 hours, kneeling 1 hour, both legs required, ability for rapid mental and muscular coordination simultaneously, near vision correctable at 13" to16" to jaeger 1 to 4, far vision correctable in one eye to 20/20 and to 20/40 in the other, both eyes, required, ability to distinguish basic colors, ability to distinguish shades of colors, hearing (aid permitted); environmental factors excessive heat, excessive cold, working alone, protracted or irregular hours of work, working closely with others.
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