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Job Title: Medical Records Technician CDIS
Company Name: Veterans Affairs, Veterans Health Administration
Location: Tucson, AZ
Position Type: Full Time
Post Date: 09/12/2018
Expire Date: 11/11/2018
Job Categories: Agriculture, Forestry, & Fishing, Computers, Software, Finance/Economics, Healthcare, Other, Healthcare, Practitioner and Technician, Information Technology, Research & Development, Medical, Writing/Authoring
Job Description
Medical Records Technician CDIS
  • Responsible for facilitating improved overall quality, education and completeness and accuracy of medical record documentation.
  • Assist with development and/or updating medical center policy memoranda pertaining to documentation improvement.
  • Serve as the technical expert in health record content and documentation requirements.
  • Accountable for utilizing a variety of collaborative strategies with physicians, mid-level providers and other members of the interdisciplinary team, Medical Care Cost Recovery (MCCR) and Health Information Management Section.
  • Provide leadership for and participates in performance improvement activities including those that support Strategic Analytics for Information & Learning (SAIL), along with the Quality and Compliance programs.
  • Apply comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medication procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
  • Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
  • Search the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
  • Adhere to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary.
Work Schedule: Monday - Friday, 0730 - 1600 or 0700 - 1530 or other as needed
Financial Disclosure Report: Not required
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.

One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work

OR

Two years above high school with a minimum of 12 semester hours directly related to Medical Records Technician work

OR

Successful completion of a course for medical technician, hospital corpsmen, medical services 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 submitted 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.

OR
I have an equivalent combinations of experience and education that incudes 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.

Preferred Experience includes the applicant being a certified medical coder through AHIMA or AAPC, or certified in Clinical Documentation Improvement, with 3-5 years' experience that includes a combination of inpatient and outpatient abstracting and coding, working with clinicians to improve their documentation and coding, creating educational tools and conducting presentations. Prefer demonstrated expert knowledge of the International Classification of Diseases (ICD), Procedural Coding System (PCS), Current Procedural Terminology (CPT), complication or co-morbidity/major complication or co-morbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators. Experience with regulatory guidelines/agencies such as Joint Commission (JC), Centers for Medicare & Medicaid Services (CMS) and Veteran Affairs (VA). Experience using Microsoft Outlook, Excel, Word and PowerPoint, as well as demonstrated competence using electronic health records and encoder software.

Grade Determinations:
GS-9: One year of experience equivalent to the next lower grade level, GS-8. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Responsible for the development and implementation of active training/education programs for all providers/clinicians to ensure the Clinical Documentation Improvement program objectives are met.

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. Ability 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 heath record;

3. Knowledge of anatomy and physiology, pathophysiology, and pharmacology;

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. Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators.

7. Knowledge of severity of illness and risk of mortality indicators; and

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, Appendix G35 Medical Record Technician Qualification Standard.

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

Physical Requirements: Position includes walking intermittently up to 2 hours, standing intermittently up to 2 hours, and seated intermittently 4-6 hours per day. There is a potential need to drive to other facilities to meet with providers and provide education.

None

To apply for this position, you must provide a complete Application Package which includes:

  • VA Application 10-2850c
  • Resume


VA Form 10-2850c Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search. required

Transcripts are REQUIRED
if you are using education to meet the Basic Qualification requirement

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, documentation to support Veterans Preference or ICTAP/CTAP documentation (for displaced Federal employees).

  • Cover Letter
  • DD-214
  • VA Application 10-2850c
  • VA Service Connection letter
  • Resume
  • SF-15
  • Transcript


Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx.
Qualifications & 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.

One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work

OR

Two years above high school with a minimum of 12 semester hours directly related to Medical Records Technician work

OR

Successful completion of a course for medical technician, hospital corpsmen, medical services 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 submitted 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.

OR
I have an equivalent combinations of experience and education that incudes 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.

Preferred Experience includes the applicant being a certified medical coder through AHIMA or AAPC, or certified in Clinical Documentation Improvement, with 3-5 years' experience that includes a combination of inpatient and outpatient abstracting and coding, working with clinicians to improve their documentation and coding, creating educational tools and conducting presentations. Prefer demonstrated expert knowledge of the International Classification of Diseases (ICD), Procedural Coding System (PCS), Current Procedural Terminology (CPT), complication or co-morbidity/major complication or co-morbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators. Experience with regulatory guidelines/agencies such as Joint Commission (JC), Centers for Medicare & Medicaid Services (CMS) and Veteran Affairs (VA). Experience using Microsoft Outlook, Excel, Word and PowerPoint, as well as demonstrated competence using electronic health records and encoder software.

Grade Determinations:
GS-9: One year of experience equivalent to the next lower grade level, GS-8. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Responsible for the development and implementation of active training/education programs for all providers/clinicians to ensure the Clinical Documentation Improvement program objectives are met.

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. Ability 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 heath record;

3. Knowledge of anatomy and physiology, pathophysiology, and pharmacology;

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. Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators.

7. Knowledge of severity of illness and risk of mortality indicators; and

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, Appendix G35 Medical Record Technician Qualification Standard.

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

Physical Requirements: Position includes walking intermittently up to 2 hours, standing intermittently up to 2 hours, and seated intermittently 4-6 hours per day. There is a potential need to drive to other facilities to meet with providers and provide education.
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Contact Information
Contact Name:
Company Name: Veterans Affairs, Veterans Health Administration
Phone Number:
Fax Number:
Contact Email:Elizabeth.Morgan@va.gov
Website:http://www.ecentralmetrics.com/url/?u=462411019307%2D254&r=http%3A%2F%2Fwww%2Evacareers%2Eva%2Egov%2Fjob%2Dsearch%2Fjob%2Ddetail%2Easp%3Fjob%3D351565
Company Description:

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