Clarification from the agency

Open to Department of Veterans Affairs Employees

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Duties Include:

• Applies comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, as well as, the principles and practices of health services and the organization structure to ensure proper code selections
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management (E&M) codes to ensure ethical, accurate, and complete coding
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA
• Assists facility providers with documentation requirements to completely and accurately reflect the patient care provided
• Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement requirements, workload, accepted nomenclature and proper sequencing of diagnoses
• Monitors the Physician Query Tracking (PQT) process, providing analysis of coded information and queries sent to providers, makes recommendations, as well as, monitors for potential query opportunities
• Ensures provider documentation is complete and supports the diagnoses and procedures coded
• Directly consults with the providers for clarification of conflicting and or ambiguous clinical data
• Reports the need for improved clinical documentation or ICD codes to the appropriate service chief for training and provider documentation/coding education classes
• Expertly searches the patient health record to find provider documentation justifying ICD code assignment based on an expanded knowledge of the organization and structure of the patient record
• Develops and conducts seminars, workshops, short courses, informational briefings, and conference concerned with health record documentation, educational and functional training requirements to ensure the CDIP objectives are met for clinical and coding staff
• Directly supports physicians, residents, nurses and all other ancillary clinical providers and administrative staff
• Performs documentation audits and coding of providers, provides feedback, and prepares formal reports for meetings, medical providers, nurse managers, Service Chiefs, and Pentad members
• Facilitates improved overall quality, completeness and accuracy of health record documentation, as well as, promotes appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff, and CDIP staff and ensures clinical documentation and services rendered to patients are complete and accurate
• 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
• As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary
• Compiles, reviews, abstracts, analyzes, and interprets medical data incidental to a variety of patient care and medical treatment activities
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues
• Provides basic education in the areas of clinical documentation, encounters, coding, copy/paste, telephone encounters and resident supervision guidelines
• Assists with reviews including but not limited to external coding audits, Joint Commission, Privacy Compliance and Assurance (PCA), Office of Inspector General (OIG), EPRP, Compliance and VISN reviews

Work Schedule: Monday-Friday 8:00AM-4:30PM
Telework: This position is Remote 100% Outside of Area
Virtual: This position is Remote-100%Outside of Area
Remote: This is a remote position
Functional Statement #:
Financial Disclosure: Not Required
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

Conditions of employment

Requirements:

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• You may be required to serve a probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

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.

Experience and Education:

(a) 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,

(b) 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;

OR,

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. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (CDIS).

• Certification:Persons hired or reassigned to MRT (CDIS) positions in the GS-0675 series in VHA must have one of the following certifications:

(1) Apprentice/Associate Level Certification through AHIMA or AAPC,
(2) Mastery Level Certification through AHIMA or AAPC,
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

• English Language Proficiency: MRTs (CDIS) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Preferred Experience: Greater than 3 years experience with inpatient/acute care ICD-10 coding, Inpatient coding certified, comfortable providing ICD-10 coding guidelines education to medical providers, senior leadership, CDI nurses, CDIS coders, and any other medical staff employee as assigned, ability to work well with minimal supervision, ability to work well as an active team member, ability to communicate effectively via written and verbal communication, and ability to meet or exceed work assignment deadlines.

Grade Determinations

GS-9 Experience: One year of creditable experience equivalent to the journey grade level of a MRT (CDIS)

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;

In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(a) Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
(b) 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.
(c) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
(d) Ability to establish and maintain strong verbal and written communication with providers.
(e) Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
(f) Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
(g) Knowledge of severity of illness, risk of mortality, and complexity of care.
(h) 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.

The full performance level of this vacancy is GS-9.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

References: VA Handbook 5005, Part II, Appendix G57, Medical Records Technician Qualification Standards.

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, resume, 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.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.