Clarification from the agency

First Area of Consideration: James E. Van Zandt VA Medical Center Second Area of Consideration: All other Federal Employees Third Area of Consideration: The public

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Duties include, but are not limited to:

• The incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Develops and conducts seminar, workshops, short courses, informational briefings, and conferences concerned with health documentation, educational, and functional training requirements to ensure program objectives are met for all levels of clinical and administrative staff.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
• Technical expert in health record documentation matters, provides advise and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules, and reimbursement issues. The documentation specialist is a member of the healthcare team.
• Reviews Maintain statistical databases to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Conditions of employment

• You must be a U.S. Citizen to apply for this job
• Designated and/or random drug testing may be required
• Selective Service Registration is required for males born after 12/31/1959
• You may be required to serve a probationary period
• Subject to a background/security investigation
• Must be proficient in written and spoken English
• Selected applicants will be required to complete an online onboarding process

Qualifications

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.

To qualify for this position, applicants must meet both basic requirements and grade determinations by the closing date of this announcement, 06/10/2020

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).

Grade Determinations: Medical Records Technician (CDIS) GS-9. Candidates must meet one of the experience requirements and certification and must demonstrate all the KSAs.

Specialized Experience: One (1) year creditable experience equivalent to the GS-8 Medical Records Technician (Coder) is required. This experience that equipped the applicant with the particular knowledge, skills and abilities associated with the work assigned to the position. Examples of specialized experience are: 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 comments, and the disease process/pathophysiology of the patient; Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines. -OR- An associate's degree or higher, & three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy & physiology, medical coding, & introduction to health records) -OR- Mastery level certification through AHIMA or AAPC & two years of experience in clinical documentation improvement -OR- Clinical experience such as RN, M.D., or DO, & 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.

• 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).

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.