Medical Records Technician (CDIS- Outpatient/Inpatient)

US-Department-of-Veterans-Affair; New Orleans (LA); On-site; USD 58,000 - 78,000; Full time

Job summary

U.S. Department of Veterans Affairs Southeast Louisiana Veterans Healthcare System in New Orleans seeks a Medical Records Technician (CDIS-Outpatient/Inpatient) to abstract data and assign codes using current classification systems.

Applicants must meet basic requirements for citizenship, English proficiency, and education/certification options. Position is at GS-9 level with potential for clinical documentation improvement responsibilities and professional certification pathways as described in

Qualifications

• Knowledge of medical terminology, anatomy and physiology, and health records.
• Familiarity with ICD, CPT, HCPCS coding and health information management procedures.
• Ability to interpret health records and apply coding guidelines.

Responsibilities

• Abstract medical record data and assign codes using current classification systems.
• Ensure accuracy and completeness of documentation for outpatient and inpatient care.

Skills

Medical coding concepts

Anatomy & physiology

Data analysis

Communication skills

Coding rules & classifications

Education

Associate's degree in HIT/HIM

12 sem hours HIT/HIM courses

AHIMA/AAPC coding program

Job description

This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System VA Medical Center. The Medical Records Technician (CDIS- Outpatient/Inpatient) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

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.

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:
• (1) 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,
• (2) 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,
• (3) 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;
• OR,
• (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service 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 substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:

1. Apprentice/Associate Level Certification through AHIMA or AAPC.
2. Mastery Level Certification through AHIMA or AAPC.
3. 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.

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;

OR,

Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

Certification:

Employees at this level must have either a mastery level certification or a clinical documentation improvement certification as per the below:

• Master Level Certification: This is considered a higher-level health information management or coding certification and is limited to those obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification & are not acceptable for qualifications. Certification titles may change & certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Cordera (COC), Certified Inpatient Coder (CIC).
• Clinical Documentation Improvement Certification: This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, & certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) & Certified Clinical Documentation Specialist (CCDS)

Demonstrated Knowledge, Skills and Abilities

i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology

ii. 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

iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.

iv. Ability to establish and maintain strong verbal and written communication with providers.

v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.

vi. 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.

vii. Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, 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.

viii. 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.

please see continuation in education below