Medical Records Technician (Clinical Documentation Improvement Specialist)(CDIS - Inpatient)

US-Department-of-Veterans-Affair; Tulsa (OK); Vor Ort; USD 55.000 - 75.000; Vollzeit

Benefits dieser Stelle

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Zusammenfassung

The James Mountain Inhofe VA Medical Center in Tulsa is seeking Allied Health professionals for clinical documentation and coding roles. This federal position requires knowledge of medical terminology, anatomy, physiology, and coding, with a pathway through AHIMA or AAPC certifications.

GS-9 MRT/CDIS-like requirements apply; candidates may have an associate degree with relevant coursework or approved coding training. The job is full-time and on-site in Tulsa, OK.

Qualifikationen

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Associate's degree with major in health information technology/management or related degree with 12 semester hours in health information technology/health information management.
• Completion of an AHIMA approved coding program or equivalent training leading to coding certification eligibility.
• Education/experience substitutions allowed as described for combining education and creditable experience.

Kenntnisse

Medical terminology

Anatomy and physiology

Pathophysiology

Medical coding

Health records

Ausbildung

Associate's degree in Health Information Technology/Health Information Management

AHIMA coding program

Courses in medical terminology, anatomy and physiology, medical coding, health records

Jobbeschreibung

Join us in shaping the future at the brand-new James Mountain Inhofe VA Medical Center! We're seeking talented Allied Health professional to make a difference in Veteran care. In 2021, Congress approved federal funding for a new Veterans Hospital in Tulsa which will be the first hospital to be built under the Communities Helping Invest through Property and Improvements Needed for Veterans Act of 2016.

Basic Requirements-

Experience and Education -

• 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.
• 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). (A transcript must be submitted with your application if you are basing all or part of your qualifications on education).
• 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.
• 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:
  • Six months of creditable experience that indicates knowledge of medical 4 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.
  • 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:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • 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.

GS 9 Grade Level Requirements

*Above Full performance*

• Experience. One year of creditable 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 (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records).
• 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.

GS 9 Certification

• Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

GS-9 MRT (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) - Knowledge, Skills, and Abilities

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order 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.
• Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
• Ability to establish and maintain strong verbal and written communication with providers.
• Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
• Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
• Knowledge of severity of illness, risk of mortality, and complexity of care.
• 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.

Reference: https://www.va.gov/ohrm/QualificationStandards/

This vacancy is being announced Above the Full Performance Level GS-9.