Medical Record Technician (Clinical Documentation Improvement Specialist - Outpatient)

Department Of Veterans Affairs Coatesville , PA 19320

Posted 3 weeks ago

  • Videos

Videos

  • Duties

Help

Duties

Summary

This position is located in the Health Information Management (HIM) section of the Health Administrative Service at the Lebanon VA Medical Center. The Medical Record Technician (Clinical Documentation Improvement Specialist (CDIS) - Outpatient) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Learn more about this agency

Responsibilities

  • Facilitate improved quality, education, and completeness and accuracy of clinical documentation within the patients health record through interaction with clinical staff and HIMS coding staff to capture patient care services rendered and workload.

  • Assists in developing and/or revising medical center policy memoranda pertaining to documentation improvement.

  • Serves as Subject Matter Expert (SME) in coding based on health record content and documentation requirements.

  • Responsible for performing reviews of health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership.

  • Responsible for the development and implementation of on-going training/education programs (seminars, workshops, informational briefings, and conferences) to ensure proper health record documentation is compliant with all established requirements.

  • Performs documentation and coding audits, providing results to providers and leadership via formal reports.

  • Conducts initial and concurrent reviews for all admissions and identifies potential documentation improvements through periodic evaluation during the patient's stay.

  • Monitors patient records for correct acuity of care are accurately reflected in the health record.

  • 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, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.

Work Schedule: Monday

  • Friday, 7:30am

  • 4:00pm or 8:00am

  • 4:30pm

This position is eligible for Telework

This position is not approved for Remote work

Financial Disclosure Report: Not required

NOTE: Salary will be determined based on duty station.

Coatesville: $57,508 - $74,762

Lebanon: $66,930 - $87,011

A RECRUITMENT or RELOCATION INCENTIVE HAS BEEN AUTHORIZED FOR A HIGHLY QUALIFIED APPLICANT.

Travel Required

Not required

Supervisory status

No

Promotion Potential

9

  • Job family (Series)

0675 Medical Records Technician

Similar jobs

  • Health Information Technicians

  • Medical Records And Health Information Technicians

  • Medical Records Specialists

  • Medical Records Technicians

  • Specialists, Medical Records

  • Technicians, Health Information

  • Requirements

Help

Requirements

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

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.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Advanced Medical Support Assistant

Department Of Veterans Affairs

Posted 3 weeks ago

VIEW JOBS 10/28/2020 12:00:00 AM 2021-01-26T00:00 * Videos Videos * Duties Help Duties Summary The Advanced Level Medical Support Assistant (MSA) position has a foundational role within the VHA Patient Aligned Care Team (PACT) initiative. Patient care is delivered in a team-based model known as the "Teamlet". Members of the teamlet include the " MSA, a Registered Nurse Care Manager, a Licensed Practical Nurse/Licensed Vocational Nurse and a Primary Care Provider Learn more about this agency Responsibilities The Advanced MSA works collaboratively in an interdisciplinary coordinated care delivery model (i.e. PACT, Specialty Clinics) and performs receptionist duties, customer service and other duties assigned for the proper and timely treatment of patients and maintains appointment schedules for one or more outpatient clinics. Some of the major duties of this position include, and are not limited to: * Assists with clinic access contingency plans by adjusting appointment times, location, or dates as well as shift patients to other healthcare providers as conflict with staffing and/or coverage occurs * Supports patient safety standards using the correct Veterans Affairs identification of all patients using two forms of identification, name and full Social Security Number * Interacts with the patient to validate and update patient demographic information, either in person during check-in or over the phone, to decrease the incidence of returned mail due to incorrect addresses and inability to contact patient by phone due to incorrect number * Explains the VA's mandate to collect insurance information to veterans, their families, and other eligible patients. He/she collects, scans, and updates insurance information serving a major role in the revenue process * Contributes to the revenue collection process by identifying patients with third party insurance * Promotes veteran registration for and utilization of My Healthy Vet (MHV) * Exhibits a caring, compassionate and sensitive manner is essential when explaining procedures to veterans and their family members both in person and on the phone * Ensures that all necessary health/administrative information are integrated into the patient's medical record in the Computerized Patient Record System (CPRS). * Performs scanning duties and may also be asked to train other MSA levels on the process * Screens/receives phone calls in a courteous and timely manner, determine the nature of requests and provide the information desired using privacy rules and established clinic processes * Schedule appointments and utilizes the Electronic Waiting List accurately in a timely manner * Conducts a daily review of active/pending consults, Electronic Wait List, Recall list and Audiocare communications for accuracy and disposition * Performs other duties as assigned Work Schedule: Full-Time, Monday - Friday, 8:00 A.M - 4:30 P.M. Financial Disclosure Report: Not required Travel Required Not required Supervisory status No Promotion Potential 6 * Job family (Series) 0679 Medical Support Assistance * Requirements Help Requirements 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 * 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. * Six months experience of clerical, office or other work that indicates the ability to acquire the particular knowledge and skills needed to perform the duties of the position; or one year above high school; or equivalent combination of experience and education are qualifying for entry level of which both education and experience are acceptable. * English proficiency. Must be proficient in spoken and written English. Assignment. The Advanced MSA [provides specialized and expert administrative patient support while working] collaboratively in an interdisciplinary coordinated care delivery model. Work involves specialized administrative judgment and the flexible use of a wide range of clinical flow processes relating to access to care across multiple clinics, specialties, and/or care in the community resources. Recommends changes to existing clinic procedures based on current administrative guidelines. Expertise in utilizing numerous advanced patient systems in support of multiple clinics involved in an interdisciplinary coordinated care delivery model. Coordinates] with the patient care team to review clinic [appointment availability utilization to ensure that clinic [schedules are] closely monitored to effectively support the needs of the clinics and adjusts as necessary. MSAs at this level] develop [and/or] maintain effective and efficient communication with the patient, interdisciplinary [coordinated care delivery model teams] , VA medical centers, and other agencies (e.g., assist with communications during the inpatient to outpatient discharge; communicate with non-VA medical facilities; [prepare correspondence] to notify patients of normal lab results; [ ] manage a [ ] system for follow-up care such as consults, tests, etc.). Grade Determinations (GS-0679-06): In addition to meeting the basic requirements above, applicants must possess one year of experience equivalent to the GS-5 level. Examples of equivalent GS-5 level work would be ability to operate computerized programs and systems in order to enter, modify, and retrieve sensitive medical and patient identifying information (PII) into or from electronic health records, scheduling systems, and/or reports; advanced knowledge of medical terminology specific to understand medical diagnosis and procedures sufficient to communicate clinical staff instructions to patients; ability to schedule medical appointments in a clinical setting; ability to work independently in the accomplishment of a wide variety of duties performing patient support work; ability to communicate effectively and professionally in person, electronically, and/or by telephone, with internal and external customers; and skill in customer service with the ability to identify customer concerns, and refer to the appropriate staff, as necessary, to ensure a satisfactory resolution. Candidates must also demonstrate all of the following knowledge, skills, and abilities at the GS-6 level. 1. Ability to collaborate and communicate with a wide range of medical clinicians across multiple disciplines (e.g. medical doctors, nurse practitioners, physician assistants, psychologists, psychiatrists, social workers, clinical pharmacists, and nursing staff) to accomplish team goal setting to ensure medical care to patients is met. 2. Ability to independently set priorities and organize work to meet deadlines, ensuring compliance with established processes, policies, and regulations. 3. Ability to communicate tactfully and effectively, electronically, by phone, in person, and in writing, with internal and external customers. This may include preparing reports in various formats and presenting data to various organizational levels, as well as resolving patient concerns. 4. Advanced knowledge of the technical health care process (including, but not limited to, scheduling across interdisciplinary coordinated care delivery and/or care in the community models and patient health care portals) as it relates to access to care. 5. Advanced knowledge of policies and procedures associated with interdisciplinary coordinated care delivery and/or care in the community operational activities that affect patient flow, and patient support care administrative functions to include, but not limited to appointment cycles, outside patient referrals, follow-up care, overbooking, provider availability, etc. 6. Advanced knowledge of medical terminology due to the technical nature of language utilized by clinicians. References: VA Handbook 5005, Part II Appendix G45. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-6. Physical Requirements: Work is performed in an office setting and is primarily sedentary. May require lifting and carrying of light loads (e.g.files, records etc.). Resume Reminder: Your resume must include the following for each job listed: 1) Job title and grade level/salary. In order to show that you meet the experience requirements, you must document grades you have held and how long you have held them; 2) Duties (you must include enough detailed information to support your specialized experience); 3) Month, day and year start/end dates (e.g. 04/02/2019 to 04/13/2020); 4) Hours worked per week for all jobs listed. 5) Full Name and address of Employer 6) Name of Supervisor or Contact name 7) Complete phone number of Supervisor/Contact. (limit characters). Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html. Department Of Veterans Affairs Coatesville PA

Medical Record Technician (Clinical Documentation Improvement Specialist - Outpatient)

Department Of Veterans Affairs