MED RECORDS TECHNICIAN Clinical Documentation Improvement Specialist (CDIS) OUTPATIENT CODER

Description:

This position is located in the Health Information Management Section (HIMS) of the Business Service at the San Francisco VA Health Care System (SFVAHCS). The CDIS is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Requirements:

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

• Certification: Persons hired or reassigned to MRT (CDIS Inpatient/Outpatient) positions in the GS-0675 series in VHA must have either below:
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

• Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.

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).

Grade Determinations : Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-9

Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and 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;

NOTE: See paragraph 2g for a detailed definition of mastery level certification;

OR,

Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. (b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

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

Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs:

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology 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.
• Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
• Ability to establish and maintain strong verbal and written communication with providers.
• Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
• Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
• Knowledge of severity of illness, risk of mortality, complexity of care for outpatients, and 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 for outpatients.
• 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

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/ .

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

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

****All required documentation must be uploaded before the announcement closes, to support eligibility.****

Failure to submit documentation will constitute the application being categorized as incomplete and therefore ineligible for referral. Experience must be clearly indicated in your resume.