- Position Title
- Medical Records Technician (Clinical Documentation Improvement Specialist-Outpatient and Inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBTG-21279-11562511-22-WLH Opens in new window
- Open Period
- Thursday, July 7, 2022 to Friday, September 30, 2022
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Do you claim Veterans’ Preference?
2.
Are you currently employed by the Department of Veterans Affairs?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
3.
Are you an employee of the facility indicated for this position?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
4.
Are you a current permanent Federal employee from an agency other than Department of Veterans Affairs?
To verify your eligibility, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50) or equivalent personnel action form.
To verify your eligibility, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50) or equivalent personnel action form.
Preferences
1.
Which of the following items describes your current or recent (within the last five years) political appointee service?
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
Resume Reminder- Your resume must include the following information for each job listed:
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
- Job title Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2007 to April 2008)
- Full-time or part-time status (include hours worked per week)
- Series and Grade, if applicable, for all Federal positions you have held
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
Accuracy of Application Reminder:
By submitting your application, you are certifying, to the best of your knowledge and belief, all the information submitted by you with your application for employment is true, complete, and made in good faith, and that you have truthfully and accurately represented your work experience, knowledge, skills, abilities and education (degrees, accomplishments, etc.). The information you provide as part of your application may be investigated. You are also certifying, and acknowledging, that misrepresenting your experience or education, or providing false or fraudulent information in, or with your application, may affect your eligibility for appointment and/or continued employment. False or fraudulent statements may be punishable by fine or imprisonment (18 U.S.C. 1001).
By submitting your application, you are certifying, to the best of your knowledge and belief, all the information submitted by you with your application for employment is true, complete, and made in good faith, and that you have truthfully and accurately represented your work experience, knowledge, skills, abilities and education (degrees, accomplishments, etc.). The information you provide as part of your application may be investigated. You are also certifying, and acknowledging, that misrepresenting your experience or education, or providing false or fraudulent information in, or with your application, may affect your eligibility for appointment and/or continued employment. False or fraudulent statements may be punishable by fine or imprisonment (18 U.S.C. 1001).
Assessment 1
Select the appropriate answer to each of the following questions based on your current level of education and/or experience and certification that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that your experience and education and certification are subject to verification by investigation. Your resume must provide specific examples or documentation of your experience as proof to support your answers. Your failure to adequately document your experience, education, or certification on your resume may result in you being found not qualified for this position. No assumptions are made regarding your qualifications.
Medical coding falls under the jurisdiction of health information management (HIM). The following are the requirements for appointment as a Medical Records Technician (MRT) (Coder) performing medical coding in the Veterans Health Administration (VHA). These requirements apply to all VHA MRT (Coder) positions in the GS-0675 series. MRTs (Coder) 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 patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).MRT (Coder) professionals may be assigned to outpatient coding, inpatient coding, or a combination of outpatient/inpatient coding. Also, this work can be performed in a consolidated coding unit (CCU). MRT (Coder) may also provide education related to coding and documentation. MRT (Coder) assignments above the journey level include clinical documentation improvement specialist (CDIS) and auditor.
Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Handbook 5005.
1.
Are you proficient in basic written and spoken English?
Definitions:
(a.) Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder).
(b.) Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means.
(c.) Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time work week. For example, an MRT would receive one week of full-time credit for each two weeks of half-time work.
(d.) Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification 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 and are not acceptable for qualifications. Certification titles may change and 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder(COC), Certified Inpatient Coder (CIC).
(e.) 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, and 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) and Certified Clinical Documentation Specialist(CCDS).
(a.) Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder).
(b.) Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means.
(c.) Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time work week. For example, an MRT would receive one week of full-time credit for each two weeks of half-time work.
(d.) Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification 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 and are not acceptable for qualifications. Certification titles may change and 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder(COC), Certified Inpatient Coder (CIC).
(e.) 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, and 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) and Certified Clinical Documentation Specialist(CCDS).
2.
All MRT (Coders) are required to have at least one of the following basic required Experience and/or Education: Select the appropriate statement that best describes your experience and/or education.
The following questions are used for grade determination as a Medical Records Technician (Clinical Documentation Improvement Specialist (CDID-Outpatient and Inpatient)), GS-09. Education, certification, and experience will be verified.
Certification. Persons hired or reassigned to MRT (CDIS-Outpatient and Inpatient), GS-09, positions in the GS-0675 series in VHA must have either (1) or (2) below:
(1) Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification 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 and are not acceptable for qualifications. Certification titles may change and 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder COC), Certified Inpatient Coder (CIC).
(2) 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, and 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) and Certified Clinical Documentation Specialist (CCDS). Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.
(1) Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification 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 and are not acceptable for qualifications. Certification titles may change and 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 Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder COC), Certified Inpatient Coder (CIC).
(2) 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, and 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) and Certified Clinical Documentation Specialist (CCDS). Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.
3.
Select the statement that best describes your certification. The only documentation accepted to verity your certification must be a screen shot or scanned printout from one of the following Websites: https://www.aapc.com/certification/credential-verification.aspx (https://www.aapc.com/certification/credential-verification.aspx) OR https://my.ahima.org/certification/credentialverification.aspx (https://my.ahima.org/certification/credentialverification.aspx) or https://acdis.org/certification/ccds/ccds. (https://acdis.org/certification/ccds/ccds)
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-09. 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. CDISs must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient). CDISs serve as the liaison between health information management and clinical staff. They are responsible for facilitating improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. They develop and/or update medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. They review health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. They monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education. They are responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met. They provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. They apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures in order to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting.
4.
For the GS-09 CDIS, select the education or experience that best describes you. Education must be supported with transcripts and experience must be documented in your resume.
Knowledge, skills, and abilities (KSAs). In addition to the experience above, you must demonstrate all of the following KSAs.
(1.) Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
(2.) 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.
(3.) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
(4.) Ability to establish and maintain strong verbal and written communication with providers.
(5.) Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
(6.) 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.
(7.) 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.
(8.) 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.
(1.) Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
(2.) 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.
(3.) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
(4.) Ability to establish and maintain strong verbal and written communication with providers.
(5.) Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
(6.) 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.
(7.) 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.
(8.) 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.
5.
I can demonstrate all of the knowledge, skills, and abilities listed above for the MRT (CDIS-Outpatient and Inpatient). This experience must be documented in your resume.
6.
I certify that, to the best of my knowledge and belief, all of the information included in this questionnaire is true, correct, and provided in good faith. I understand that if I make an intentional false statement, or commit deception or fraud in this application and its supporting materials, or in any document or interview associated with the examination process, I may be fined or imprisoned (18 U.S.C. 1001); my eligibilities may be canceled; I may be denied an appointment; or I may be removed and debarred from Federal service (5 C.F.R. part 731). I understand that any information I give may be investigated and that responding "No" or providing no response to this item will result in my not being considered for this position.
ALTHOUGH NOT REQUIRED, ITS HIGHLY RECOMMENDED THAT APPLICANTS COMPLETE THEIR RESUME' USING THE USAJOBS RESUME' BUILDER. Resume Reminder - Your resume must include your contact information (phone/email) and must include the following information for each job listed: (REQUIRED)
(1.) Employer's Name
(2.) Employer's City, State
(3.) Job title (if a federal job, separate by grade level(s))
(4.) Month & year start/end dates (e.g. June 2007 to April 2008 or 06/07-04/08)
(5.) Full-time or part-time status (include hours worked per week for part-time schedules...i.e. 32 hours per week, 20 hours per week, etc.
(6.) Duties (be as detailed as possible) Even though we do not require a specific resume format, your resume must be clear so that we can fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. Details of your experience and clearly document your ability to demonstrate the KSAs of grade level you are applying to.
We cannot make assumptions regarding your qualifications
(1.) Employer's Name
(2.) Employer's City, State
(3.) Job title (if a federal job, separate by grade level(s))
(4.) Month & year start/end dates (e.g. June 2007 to April 2008 or 06/07-04/08)
(5.) Full-time or part-time status (include hours worked per week for part-time schedules...i.e. 32 hours per week, 20 hours per week, etc.
(6.) Duties (be as detailed as possible) Even though we do not require a specific resume format, your resume must be clear so that we can fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. Details of your experience and clearly document your ability to demonstrate the KSAs of grade level you are applying to.
We cannot make assumptions regarding your qualifications
7.
I have read and understand the requirements for a complete resume. Failure to follow the instruction for a complete resume will result in NOT being referred.
VA form 10-2850C - Application for Associated Health Occupations is a (REQUIRED) document. This document must be completed and signed and dated where indicated. Failure to submit this completed document will render the applicant ineligible for consideration. You may print the form, complete, sign and date it then either scan it to USAJOBS document and follow the instructions to attach it to your application or you may fax it following the faxing instruction in the ALTERNATE APPLICATION section of the vacancy announcement.
Additional required documentation may be required such as transcripts, copy of certification from an approved AHIMA or AAPC Website, and applications and will be indication in the vacancy announcement as "Required". Failure to provide the "Required" document will result in not being referred. Proof of certification must be provided from one or both of the following Websites: https://www.aapc.com/certification/credential-verification.aspx (https://www.aapc.com/certification/credential-verification.aspx) OR https://my.ahima.org/certification/credentialverification.aspx (https://my.ahima.org/certification/credentialverification.aspx).
8.
I have read and understand the requirements for a complete application. Failure to follow the instructions and failure to provide the required document(s) will result in NOT being referred.