Medical Records Technician (CODER AUDITOR) INPATIENT/OUTPATIENT

US-Department-of-Veterans-Affair; Los Angeles (CA); On-site; USD 52,000 - 78,000; Full time

Job summary

The U.S. Department of Veterans Affairs invites applications for a Medical Records Technician (CDIS-Outpatient) at the VA Greater Los Angeles Healthcare System.

This GS-9 role sits in the Health Administration Service and Health Information Management section and focuses on clinical documentation improvement in outpatient settings. Candidates must meet citizenship, education/experience, and certification requirements.

Qualifications

• One year of creditable experience with medical terminology and health records structure.
• Associate's degree with 12 semester hours in health information management.
• Completion of AHIMA approved coding program or equivalent training.
• Combination of education and experience allowed with substitutions.

Skills

Medical terminology

Anatomy & physiology

Medical coding knowledge

Documentation improvement knowledge

Education

Associate's degree in health information technology/health information management

AHIMA/AAPC coding program completion

Education/experience substitutions for combined qualifications

Job description

This position is located in the Health Administration Service (HAS), Health Information Management ( HIM) section at the VA Greater Los Angeles Healthcare System. MRTs (Auditor) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, group practices, multi-specialty clinics, and specialty centers.

Basic Requirements

• a. 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.)
• b. 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).
• c. 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.

English Language Proficiency.

MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f)

Grade Determinations

Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)), GS-9

• (a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
• 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 Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.
• (b) Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification.
• (c) In addition to the experience above, Must demonstrated Knowledge, Skills, and Abilities listed below:
• 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.

References: VA Handbook 5005/122 December 10, 2019 PART II APPENDIX G57

Physical Requirements:

This position is primarily sedentary.