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Medical Records Technician (CDIS Coder)


  • Duties
    Help Duties Summary

    This position is located in the Health Information Management (HIM) section at the Loma Linda VA Healthcare System. The MRT-Clinical Documentation Improvement Specialist (CDIS) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations; developing and/or update medical center policy memoranda pertaining to documentation improvement; Serves as technical expert in health record content and documentation requirements; responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups; obtaining appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary; adheres to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements; responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.

    Work Schedule: 8:00am-4:30pm, Monday-Friday: Subject to change depending on the needs of the service.
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    Responsibilities

    The Professional Standards Board (PSB) (a peer-review group) will review the selected candidate's education and experience and recommend the grade and salary at which the candidate will be placed. For Internal selectees for promotion, the board will determine grade and HR will determine step in accordance with policy. The salary is based on the grade and step approved for the selected candidate.

    Travel Required
    Not required

    Supervisory status
    No

    Promotion Potential
    9

  • Job family (Series)
    0675 Medical Records Technician

    Similar jobs
    • Medical Records Specialists
    • Specialists, Medical Records


  • Requirements
    Help Requirements Conditions of Employment
    • You must be a U.S. Citizen
    • Designated and/or random drug testing required
    • 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 a background/security investigation

    Qualifications
    Qualifications for GS-9: One year of directly related experience equivalent to the GS-8 grade level in Federal Service.

    Specialized Experience that is directly related to this position includes:
    Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services. Directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies.

    CCS/CCSP certification from AHIMA or CPC certification from AAPC are preferred coding credentials.

    Demonstrated KSAs.
    In addition to the experience above, the candidate must demonstrate the following KSAs:

    1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology;

    2. Ability 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 heath record;

    3. Knowledge of anatomy and physiology, pathophysiology, and pharmacology;

    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. Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators.

    7. Knowledge of severity of illness and risk of mortality indicators; and

    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.

    Physical Requirements: Work requires a moderate amount of physical activity including walking, standing, bending, lifting, reaching, pulling, and carrying medical records (20-30lbs).

    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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html .

    Additional information

    This job opportunity announcement may be used to fill additional vacancies.

    Selected applicants will be required to complete an online onboarding process.

    It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

    This position is in the Excepted Service and does not confer competitive status.

    United States Citizenship Required; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

    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.

    Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

    If you are unable to apply online view the following link for information regarding an Alternate Application .

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    How You Will Be Evaluated

    You will be evaluated for this job based on how well you meet the qualifications above.

    IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

    NOTE:
    Applicant's education and experience will be reviewed by a Professional Standards Board and utilized in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy.

    Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

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    Background checks and security clearance

    Security clearance
    Public Trust - Background Investigation

  • Required Documents
    Help Required Documents

    To apply for this position, you must provide a complete Application Package which includes:

    • Resume


    VA Form 10-2850 can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search .

    The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), etc.

    Current or Former Federal Employees - Must provide a copy of your last or most recent SF-50, "Notification of Personnel Action" which shows your current grade level. If you have served at a higher grade level in Federal service which qualifies you for this position, please provide a copy of that SF-50.

    • Resume


    Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx .

    If you are relying on your education to meet qualification requirements:
    Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education .

    Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

  • Benefits
    Help Benefits

    A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits .

    Review our benefits

    Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.

  • How to Apply
    Help How to Apply

    All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 04/18/2018 to receive consideration.
  • To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
  • Click Submit My Answers to submit your application package.

  • NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

    To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login , select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.

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    Agency contact information Juan Cruz

    Phone
    909-825-7084 X6517
    Email
    [email protected]

    Address

    Jerry L Pettis Memorial Veterans Hospital
    11201 Benton Street
    Loma Linda, CA
    US

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    Next steps

    Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

    You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center .

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  • Fair & Transparent
    Fair & Transparent
    The Federal hiring process is setup to be fair and transparent. Please read the following guidance.
    Equal Employment Opportunity Policy

    The United States Government does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.
    • Equal Employment Opportunity (EEO) for federal employees & job applicants

    Read more Reasonable Accommodation Policy

    Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the application and hiring process should contact the hiring agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.

    A reasonable accommodation is any change to a job, the work environment, or the way things are usually done that enables an individual with a disability to apply for a job, perform job duties or receive equal access to job benefits.

    Under the Rehabilitation Act of 1973, federal agencies must provide reasonable accommodations when:
    • An applicant with a disability needs an accommodation to have an equal opportunity to apply for a job.
    • An employee with a disability needs an accommodation to perform the essential job duties or to gain access to the workplace.
    • An employee with a disability needs an accommodation to receive equal access to benefits, such as details, training, and office-sponsored events.


    You can request a reasonable accommodation at any time during the application or hiring process or while on the job. Requests are considered on a case-by-case basis.

    Learn more about disability employment and reasonable accommodations or how to contact an agency.

    Read more Legal and regulatory guidance
    • Financial suitability
    • Social security number request
    • Privacy Act
    • Signature and false statements
    • Selective Service
    • New employee probationary period



This job originated on www.usajobs.gov . For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/495520000 . Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.
Company
Veterans Affairs, Veterans Health Administration
Posted
04/06/2018
Type
Full time
Location
Loma Linda, California, US