Clarification from the agency

Open to current, permanent employees of the Department of Veteran Affairs

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As a Medical Records Technician ( Clinical Documentation Improvement Specialist (Inpatient), you will be responsible for classifying medical data from patient health records in the hospital. You must possess expertise in ICD, CPT, and HCPCS clinical classification systems. Other duties including:

• Serving as the liaison between Health Information Management and clinical staff.
• Reviewing documentation and facilitating modifications to the health record to ensure accurate complexity of care and utilization of resources.
• Identifying opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients.
• Querying clinical staff to clarify ambiguous, conflicting, or incomplete documentation. Reviews appropriateness of and responses to queries through review of query reports.
• Reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house.
• Reviewing clinical documentation and provides education to clinical staff on inpatient episodes of care including admissions and discharges, surgical cases, observation and professional services provided in the Emergency Department.
• Developing criteria, collecting data, analyzing and graphs results, creating reports, and communicating orally and/or in writing to appropriate groups and leadership.
• Obtaining appropriate corrective action plans from responsible clinical service chiefs and recommending improvements or changes in documentation practices when applicable.
• Monitoring trends in the industry and/or changes in regulations that could or should impact coding and documentation practices and identifies who who may require education.
• Uses a variety of computer applications in day to day activities and duties, such as Microsoft Outlook, Excel, Word, Teams and PowerPoint Access; competent in use of the health record applications (VistA Imaging and CPRS) as well as the encoder product suite.
• Developing and implementing active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDI program objectives are met.
• Providing training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices.

Work Schedule: Monday-Friday; 6:30am-3:00pm, 7:00am-3:30pm, 7:30am-4:00pm, 8:00am-4:30am, 8:30am-5:00pm all tours are EST
Virtual: This is a Remote position
Functional Statement #: 000000
Financial Disclosure Report: Not required

Conditions of employment

• 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.
• 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.
• English Language Proficiency: 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 and meet the criteria).
All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:
(1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
(2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
(3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
(4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
(5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

Grade Determinations: GS-9

Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-inpatient);

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,

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.

AND,

Demonstrated Knowledge, Skills, and Abilities. 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 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.
7. Knowledge of severity of illness, risk of mortality, and complexity of care
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.

Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, 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. 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.

Preferred Experience: Current or previous experience coding various clinical specialties at a level 1a VA medical center or DOD.

References: VA Handbook 5005/122 Part II APPENDIX G57

The full performance level of this vacancy is GS9. The actual grade at which an applicant may be selected for this vacancy is in the GS 9.

Physical Requirements: The work is generally sedentary but requires use of fingers for typing, etc. May require light lifting and carrying (under 15 pounds). The tasks may require long periods at a desk working on personal computer or other piece of equipment.

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.