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Medical Records Technician (Clinical Documentation Improvement Specialist)
Company: Veterans Health Administration
Location: Columbia, SC
Employment Type: Full-Time
Date Posted: 12/02/2021
Expire Date: 01/29/2022
Job Categories: Agriculture, Forestry, & Fishing, Healthcare, Other, Healthcare, Practitioner and Technician, Information Technology, Research & Development, Medical
Job Description
Medical Records Technician (Clinical Documentation Improvement Specialist)
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: Candidates must be proficient in written and spoken English. Experience and Education: Must have one of the following: Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. Or, Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records). 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: Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification. GS-9 GRADE REQUIREMENTS: Must have one of the following: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); 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; GS-9 Demonstrated Knowledge, Skills, and Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of 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 5005/122, Part II, Appendix G57 - Medical Records Technician (Coder) Qualification Standard GS-675. Physical Requirements: May include but not limited to standing up to two hours per day, use of both hands, use of fingers, and sitting up to eight hours per day; light lifting and carrying, under 15 pounds; repetitive computer use.
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