Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS)

Summary The Medical Records Technician - Clinical Documentation Improvement Specialist - Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS). Summary The Medical Records Technician - Clinical Documentation Improvement Specialist - Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS). 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 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 Experience One (1) 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 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 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 Loss of Credential Following initial certification - credentials must be maintained through rigorous continuing education - ensuring the highest level of competency for employers and consumers An employee in this occupation who fails to maintain the required certification must be removed from the occupation - which may result in termination of employment At the discretion of the appointing official - an employee may be reassigned to another occupation for which he/she qualifies - if a placement opportunity exists.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 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 NOTE: See paragraph 2g above 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 Certification Employees at this level must have either a mastery level certification or a clinical documentation improvement certification NOTE: See paragraph 2g and 2h for a detailed definition of mastery level certification and clinical documentation improvement certification 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 Reference: For more information on this qualification standard - please visit The full performance level of this vacancy is GS-09 Physical Requirements: No additional physical requirements. Duties Recruitment Incentive (Sign-on Bonus):Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year).Selected applicants may qualify for credit toward annual leave accrual - based on prior work experience or military service experience Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66 Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Remote:100% remote - pending exemption to RTO EO Telework: Maybe Authorized Virtual: This is not a virtual position Functional Statement #: 30326F Permanent Change of Station (PCS): Not Authorized Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized As a Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient and Inpatient - you will be responsible: Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided provides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencing Ensures provider documentation is complete and supports the diagnoses and procedures coded Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data Reports incorrect documentation or codes in the electronic patient health record Collaboratively working with the professional clinical staff and provides support and education on documentation issues Assists in the development of guidelines for data compatibility - consistency - and monitoring for compliance to improve the quality for clinical - financial - and administrative data to ensure that all information is fully documented and supported Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided Compiling - reviewing - abstracting - analyzing and interpreting medical data incidental to a variety of patient care and treatment activities Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay Reviews the health record and discusses the case with the clinical staff Performs admissions reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation - lab results - diagnostic information and treatment to ensure documentation reflects severity of illness - acuity and resource consumption Other duties as assigned Work Schedule: Monday - Friday - 8:00 am - 4:30 pm(Note: Work schedules are determined and approved by the supervisor The incumbent may be required to work various shifts on a permanent or temporary basis based on facility/patient care needs). #J-18808-Ljbffr U.S. Department of Veterans Affairs