[Hiring] Medical Records Technician (Clinical Documentation Improvement Specialist Outpatient and Inpatient) @Long Beach VA Medical Center

Role Description

This position is located in the Health Information Management (HIM) section at the VA Long Beach Healthcare System. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Responsible for reviewing the overall quality and completeness of clinical documentation.
• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
• Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
• Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
• Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
• Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay.
• Reviews the health record and discusses the case with the clinical staff.
• Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record.

This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Any selected candidate must live within 50 miles of a VA Medical Center. Salary will be adjusted according to your locality.

Work Schedule

• Monday-Friday from 8:00am-4:30pm
• Telework: Available
• This is not a virtual position.

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: Pharmacy Technician candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f).
• Experience or Education:
• 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, 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.
• 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.
• OR, equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Grade Determinations: GS-09
• In addition to meeting the basic requirements, to qualify for the GS-09 you must possess at least 1 year of creditable experience equivalent to the journey grade level of an MRT (Coder-Outpatient and Inpatient) (GS-08);
• OR, must possess an associate's degree or higher, and three years of experience in clinical documentation improvement;
• OR, must possess a mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement.
• OR, have clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

Benefits

• For more information on this qualification standard, please visit VA Handbook Part II Appendix G57 Medical Records Technician (Coder) GS-0675-9 .
• The full performance level of this vacancy is GS-09.

Physical Requirements

• The work is sedentary. Typically, the employee may sit comfortably to do the work. However, there may be some walking, standing, bending, lifting and carrying of light items like paper, files or books.