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Medical Record Technician (Clinical Documentation Improvement Specialist - Outpatient)
Company: Veterans Affairs, Veterans Health Administration
Location: Multiple Locations, US
Employment Type: Full-Time
Date Posted: 10/28/2020
Expire Date: 12/03/2020
Job Categories: Agriculture, Forestry, & Fishing, Healthcare, Other, Healthcare, Practitioner and Technician, Human Resources, Information Technology, Research & Development, Medical
Job Description
Medical Record Technician (Clinical Documentation Improvement Specialist - Outpatient)
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 11/03/2020. Basic Requirements:
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 experience and education are qualifying. The following educational/ training substitutions are appropriate for combining education and experience:
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials: Mastery Level Certification through AHIMA or AAPC. Current mastery level certifications include: 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 through AHIMA or ACDIS. Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist (CCDS). Grade Determinations for the GS-9: MRT (CDIS-Outpatient)
Qualified applicants must demonstrate one year of experience equivalent to the next lower grade MRT (Coder) GS-8 and demonstrate the additional knowledge, skills and abilities at the MRT (CDIS-Outpatient) GS-9. GS-8 MRT (Coder-Outpatient) Journey Level
(a) Experience.
1. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR
2. 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,
3. Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR
4. Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient;
2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding; and
3. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete and inadequate guidelines. GS-9 MRT (CDIS-Outpatient)
(a) Experience.
1. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); OR
2. 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,
3. Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR
4. Clinical experience, such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
2. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order 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;
3. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
4. Ability to establish and maintain strong verbal and written communication with providers.
5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
6. Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS).
7. Knowledge of 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.
8. 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 MEDICAL RECORD TECHNICIAN Qualification Standard. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-9. 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.
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