Medical Records Technician -- Clinical Documentation Improvement Specialist
View the full job description and apply direct: https://www.usajobs.gov/job/850657500{rel="noopener noreferrer" target="_blank"}
Duties and responsibilities include but are not limited to:
This position is part of the Health Information Management (HIM) section at the VA Western Colorado Health Care System.
Medical Records Technicians (MRTs) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patient's health records and assign alpha-numeric codes for each diagnosis and procedure.
Applies comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
Requirements:
United States Citizenship
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.
OR
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
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 timethe program was completed;
OR
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.
OR
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.
Position Highlights:
Work Schedule: Full time: 8:00am -- 4:30pm, Monday -- Friday
Onsite: Role is in-person at the Grand Junction, CO VA Medical Center
Strong work/life balance at a mid-sized medical facility with a strong patient focus
Paid Time Off: Accrual of annual leave/PTO and sick leave plus 11 paid federal holidays
Excellent Federal Benefits: Insurance - Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Retirement: Social Security plus traditional federal pension (5-year vest), and federal 401K
Compensation: Competitive base salary range: $61,722 - $80,243 per year.
About us:
We serve those who served our country providing critical medical services including acute and chronic inpatient and outpatient care. The facility consists of 62-bed capabilities for surgical procedures, specialty care, mental health outpatient services, as well as a Community Living Center, social programs and services, onsite lab, plus primary care, outpatient specialty clinics, and 4 outlying, community clinics. The service area encompasses western Colorado and eastern Utah regions. Grand Junction is an outdoor recreational hub; a small-size metro community set in the high desert and mesas of the Rocky Mountains. Come enjoy the majestic beauty and mild climate of the western Colorado canyons and countryside.
Click the link to view the full job description and apply direct: https://www.usajobs.gov/job/850657500{rel="noopener noreferrer" target="_blank"}
