[Hiring] Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)) @Bronx VA Medical Center

Role Description

This position is in the Health Information Management Service (HIMS) at James J. Peters VA Medical Center. The incumbent is responsible for reviewing the overall quality and completeness of clinical documentation.

• Temporarily eligible for Remote work within 50 miles of a VA Medical Center.
• May fall under the Presidential Memorandum titled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review.
• Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)), GS-9 Assignment.
• Inpatient CDISs must be able to perform all duties of a MRT (Coder-Inpatient).
• Serve as the liaison between health information management and clinical staff.
• Responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff.
• Review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
• Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity.
• Recommend changes and/or update medical center policy pertaining to clinical documentation improvement.
• Serve as a technical expert in health record content and documentation requirements.
• Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
• Review appropriateness of and responses to queries through review of query reports.
• Perform reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate groups and leadership.
• Obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.
• Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements.
• Monitor trends in the industry and/or changes in regulations that could or should impact coding and documentation practices and identify who may require education.
• Responsible for the development and implementation of active training/education programs for all clinical staff to ensure the CDIS program objectives are met.
• Provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques.
• Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses, and complete significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting.

Qualifications

• Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.
• 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 (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• 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.
• 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.
• Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification or Mastery Level Certification through AHIMA or AAPC.

Requirements

• Experience equivalent to the journey grade level of a MRT (Coder-inpatient).
• An associate's degree or higher, and three years of experience in clinical documentation improvement.
• Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement.
• Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.
• Demonstrated Knowledge, Skills, and Abilities (KSAs) must be demonstrated on your resume or submitted as a supporting document as part of your application package.

Benefits

• Work Schedule: Monday to Friday, 8:00am to 4:30pm EST.
• Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.
• Selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs).
• Telework: Not applicable, this is a remote position.
• Virtual: This is not a virtual position.
• Relocation/Recruitment Incentives: Not Authorized.
• Permanent Change of Station (PCS): Not Authorized.

Education Requirements

• Transcripts are not required but should be included with application materials if basing any of your qualifications on education.
• 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.
• 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.

Physical Requirements

See VA Handbook 5019.