Medical Records Technician Coder (Clinical Documentation Improvement Specialist)
Company: Veterans Health Administration
Location: Kansas City
Posted on: April 9, 2021
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Job Description:
To qualify for this position, applicants must meet both basic
requirements and grade determinations by the closing date of this
announcement, 12/31/2021. 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 or Education. Candidates must meet one of the
following:(1) 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,(2) 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,(3) 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,(4) 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: (a) 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. (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 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
must have Clinical Documentation Improvement Certification through
AHIMA or ACDIS. English Language Proficiency. MRT (CDIS) employees
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). Grade Determinations:
Medical Records Technician (Clinical Documentation Improvement
Specialist (CDIS-Outpatient and Inpatient)), GS-9. Candidates must
meet one of the experience requirements and certification and must
demonstrate the KSAs. Experience. One year of creditable experience
equivalent to the journey grade level of a GS-8 MRT
(Coder-Outpatient and Inpatient). This experience is described as:
independently selects and assigns codes from current versions of
ICD CM, PCS, CPT, and HCPCS classification systems to both
inpatient and outpatient records; reviews and abstracts clinical
data from the record for documentation of diagnoses and procedures;
consults with clinical staff for clarification of conflicting,
incomplete, or ambiguous clinical data in the health record. 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 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. Demonstrated Knowledge, Skills, and Abilities. In
addition to the experience above, the candidate must demonstrate
all of the following 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 and 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 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. 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, and level of E/M service provided
for outpatients. viii. 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 dated December 10, 2019. 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. Employee also
extracts information from computer systems which requires ability
to utilize keyboards or other similar devices.
Keywords: Veterans Health Administration, Kansas City , Medical Records Technician Coder (Clinical Documentation Improvement Specialist), Professions , Kansas City, Kansas
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