Veterans Affairs, Veterans Health Administration Medical Records Technician (Clinical Documentaton Improvement Specialist) in Louisville, Kentucky

Job Overview

Job Overview
Summary

Vacancy Identification Number (VIN)1976030

OUR MISSION: To fulfill President Lincoln's promise – "To care for him who shall have borne the battle, and for his widow, and his orphan" – by serving and honoring the men and women who are America's Veterans.

As a VA professional, your opportunities are endless. With openings in multiple functions of VA, you will have a wide range of opportunities and leadership positions at your fingertips. Not only is the VA the largest, most technologically advanced integrated health care system in the Nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries. VA offers generous paid time off and a variety of predictable and flexible scheduling opportunities.

The Robley Rex Veterans Affairs Medical Center (VAMC) improves the health of our veterans by providing a continuum of care through an integrated health care delivery system. We are a tertiary care facility classified as a level 1c facility affiliated with the University of Louisville, as such integrates teaching, research, and advanced patient care, making it an attractive academic medical center. The facility offers a full spectrum of comprehensive health care services, using state-of-the-art technology and innovative programs, as well as education and research benefits to Veterans residing in 40 counties in central and western Kentucky and in southern Indiana.

How would you like to become a part of a team providing compassionate care to Veterans?

For more information on the Department of Veterans Affairs, go to http://www.vacareers.va.gov/

YOU CAN MAKE A DIFFERENCE

VA encourages persons with disabilities to apply! The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

Note: The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate.

WORK SCHEDULE: Monday through Friday, 8:00 am to 4:30 pm

Functional Statement Title/#: Functional Statement

Duties

This position is located in the Health Information Management (HIM) section of the Business Office at the Robley Rex VA Medical Center. The Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Clinical Documentation Improvement Specialists are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. 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. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.

Physical Requirements: Light lifting under 15 lbs; moderate carrying, 15-44 lbs; reaching above shoulder, use of fingers, standing 4-6 hours, and hearing (aid permitted).

Travel Required
  • Not Required
Relocation Authorized
  • No

Job Requirements

Job Requirements
Key Requirements
  • U.S. Citizenship
  • Must pass pre-employment examination
  • English Language Proficiency required
  • Designated and/or Random Drug Testing required
  • Background and/or Security Investigation required
  • Selective Service Registration is required for males born after 12/31/1959
Qualifications

BASIC REQUIREMENTS

Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)

English Language Proficiency. MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Creditable Experience

Knowledge of Current Medical Record Technology. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current health information or health record technology and may be paid or non-paid employment.

Quality of Experience. Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be equivalent to the next lower grade level. Experience satisfying this requirement must be active practice, which is paid/non-paid employment as a MRT in the coding practice.

PREFERRED CRITERIA:

At least 5 years of inpatient coding experience, and credentialed in one of the following:

(1) Registered Health Information Administrator (RHIA);

(2) Registered Health Information Technician (RHIT);

(3) Certified Coding Specialist (CCS);

(4) Certified Coding Associate (CCA);

(5) Certified Coding Specialist-Physician-based (CCS-P);

(6) Certified Professional Coder (CPC); or

(7) Certified Professional Coder-Hospital (CPC-H).

Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

*GS-9 MRT (Coder) CDIS *

Experience. One year of experience equivalent to the next lower grade level (GS-8) meeting 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 comments, 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 coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and; and 3) Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

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.

  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.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Note: The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate.

References: VA Handbook 5005/79, Part II, Appendix G35, MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARD, dated September 2014.

APPLICANTS PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement.) Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Applicants can verify accreditation at the following website: http://ope.ed.gov/accreditation/

All education claimed by applicants will be verified by the appointing agency accordingly.

Unofficial transcripts are required whenever qualifying based on education. Education must demonstrate the knowledge, skills, and abilities necessary to do the work. A transcript or course listing must be submitted with your application if you are basing all or part of your qualifications on education. Applications submitted without this information may not be considered.

Original transcripts will not be returned.

* You can receive credit for education received outside the United States if it is comparable to an accredited educational institution in the United States at the time of application. If 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.*

Veterans Preference: When applying for Federal Jobs, eligible Veterans should claim preference on the Occupational Questionnaire in the section provided and provide a legible copy of your DD-214 and/or documentation related to your active duty service which shows dates of service, character of service (honorable, general, etc.) or 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 Veterans Preference" with required proof as stated on the form. For more information, please review the information for disabled Veterans in the application checklist or visit http://www.fedshirevets.gov/job/vetpref/index.aspx.

Security Clearance

Public Trust - Background Investigation

Additional Information

Additional Information
What To Expect Next

After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. During our review, if your résumé and application package do not support your questionnaire answers, we will adjust your rating accordingly. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email (if provided); otherwise, applicants will receive a notification letter via the U.S. Postal Service.

Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USAJOBS account and clicking on "Application Status." For a more detailed update of your status, click on "more information."

BENEFITS

Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, thrift savings plan, and participation in the Federal Employees Retirement System. In addition to traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life. For more information please visit us at http://www.va.gov/JOBS/JobBenefits/benefits.asp.

Other Information

This job opportunity may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

Placement Policy: The posting of this announcement does not obligate management to fill a vacancy or vacancies by promotion. The position may be filled by reassignment, change to lower grade, transfer, appointment, or reinstatement. Management may use any one or any combination of these methods to fill the position.

Vet-Pro (VA electronic credentialing system):Upon selection, you will be provided with information on how to use Vet-Pro. Vet-Pro was implemented on July 1, 2005. As part of the VA's pre-appointment process, it is necessary for you to submit complete information concerning your professional education, training, experience, licensure, certificate, or registration using Vet-Pro. Vet-Pro credentialing must be successfully completed prior to entering on duty.

This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/472440000. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.

Salary Range: $49,765.00 to $64,697.00 / Per Year

Series & Grade: GS-0675-09/09

Supervisory Status: No

Who May Apply: United States Citizens

Control Number: 472440000

Job Announcement Number: VHA-603-17-RY1976030-E-NB