Summary These positions are located in the Health Information Management Section (HIMS) of the Business Office at the VA Boston Health Care System (VABHCS) West Roxbury, MA. Responsibilities The Clinical Documentation specialist will provide active concurrent/retrospective review, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect documentation associated with MS-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules. As a Clinical Documentation Specialist, incumbent is responsible for providing ongoing education to our providers and coding team members by conducting initial and extended-stay concurrent review on selected admissions and document findings identifying missed opportunities and clinical documentation improvements which will both enhance the quality of the health record documentation, maximize VERA and 3rd Party Collections. Incumbent identifies co-morbidities and complications and documents appropriately. Incumbent queries the medical staff and other clinical caregivers as necessary via written/verbal communication to obtain accurate and complete documentation. Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding, compliance issues, profiling concerns, and reimbursement changes according to VA regulations and policies. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic medical record. Advise and assist the Health Information Management section in the identification of training, in-services or educational needs of personnel. In addition, Clinical Documentation Specialist will present educational resources to the health information management staff and the professional staff as needed or provide goals as requested. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Conducts re-reviews of codes abstracted for patient encounters identified by the VISN VERA Committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Performs other related duties as assigned. Work Schedule: Full time 7:00am to 3:30pm (Can be negotiated at time of interview) Compressed/Flexible: Not Authorized Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: PDF01480 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized NOTIFICATIONS: This position is an NAGE bargaining unit positions. Current and former Federal employees may submit copies of their most recent non-award SF-50 (notice of Personnel Action). The SF-50 must identify the position, title, series, grade, step, tenure and @type of service (competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held. This position is in the Excepted Service. This position is covered by locality-based comparability pay. The incumbent may be required to travel to other VA campuses and CBOC's. Veterans' preference does not apply for internal or other current permanent Federal agency employees. Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Qualifications Applicants must be fully qualified by the closing date of this announcement. 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 Grade Determination: (a) Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-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; NOTE: See paragraph 2g above for a detailed definition of mastery level certification. OR, Clinical experience such as RN, M.D., or 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. NOTE: See paragraph 2g and 2h for a detailed definition of mastery level certification and clinical documentation improvement certification. Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii. 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. 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 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. vii. Knowledge of severity of illness, risk of mortality, and complexity of care. viii. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may betechnical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. Preferred Experience: LIS, Interface building, DI Instrument Manager, VISATA and Rule Writing. References: VA Handbook, 5005/72, Part II, Appendix G-24 Physical Requirements: The work requires regular and recurring physical exertion such as standing for long periods of time, bending and stress and strain related to meeting the demands of the Medical Staff of an acute care hospital. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are 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. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. 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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
