Medical Records Technician (Coder) Clinical Documentation Improvement Specialist
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 06/19/2020. 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 Grade Determinations: GS-9 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient) Experience. One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder-Outpatient and Inpatient); OR, Education .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, Certification. Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series and grade held, including positive education that is part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees may be reassigned, promoted up to and including the full performance (journeyman) level, or changed to lower grade within the occupation, but may not be promoted beyond the journeyman level or placed in supervisory or managerial positions. (2) MRTs who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed, on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (3) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation. (4) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. English Language Proficiency. MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). Preferred Experience: Minimum (3) years acute inpatient and surgical coding experience to include knowledge of ICD-9-CM, ICD-10.CM, PCS and CPT coding; Excellent communication skills verbal, nonverbal and written; Clinical understating of Pharmacology, pathophysiology, labs, radiology and disease processes; Clinical documentation knowledge as it relates to DRG's, CPT's, POA's, MCC's and CC's preferred; Ability to establish good customer relationships with trust and respect; Knowledge of AHA Coding Clinic and AHIMA Query Practice Briefs; Ability to speak in small or large groups with clinical and administrative staff on clinical documentation; CDIS, RHIA, CCS, CPC credentials a plus or RHIA, or RHIT eligible. Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. Mastery Level Certification: 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 Certification. This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, and 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 (CDIP) and Certified Clinical Documentation Specialist (CCDS). In addition to the experience above, the candidate must demonstrate 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 5005/79 Part II Appendix G57 The full performance level of this vacancy is GS-09. Physical Requirements: Work is sedentary with the majority of the time spent sitting. The nature of the work is administrative in an office type setting working on a computer. Lifting and carrying (under 15 lbs.) would be occasional but only in direct support of the administrative duties required by the nature of the work. The position requires periods of standing (2 hours), walking (2 hours), use of fingers and both hands.