Duties

    Summary

    Clinical Documentation improvement Specialists are responsible for facilitating improved overall quality, education, completeness and accuracy of medical record documentation and 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.

    Responsibilities

    Clinical Documentation improvement Specialists (CDIS) Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve 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. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of

    Work Schedule: Monday- Friday 7:30 a.m. - 4:00 p.m.
    Fi nancial Disclosure Report: Not required

    Travel Required

    Occasional travel - You may be expected to travel for this position.

    Supervisory status

    No

    Promotion Potential

    9

  • Job family (Series)

    0675 Medical Records Technician

    Similar jobs

    • Medical Records Specialists
    • Specialists, Medical Records
  • Requirements

    Requirements

    Conditions of Employment

    • You must be a U.S. Citizen to apply for this job
    • Designated and/or random drug testing may be required
    • Selective Service Registration is required for males born after 12/31/1959
    • You may be required to serve a probationary period
    • Subject to a background/security investigation
    • Must be proficient in written and spoken English
    • Selected applicants will be required to complete an online onboarding process

    Qualifications

    To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 07/02/2019.
    Basic Requirements :
    • United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
    • Must be proficient in written and spoken English
    • One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) need to perform MRT work.
      OR
      Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g. courses in medical terminology, anatomy & physiology, and introduction to health records).
      OR
      Equivalent combinations of experience of education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
      • Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses.
      • 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.
    Preferred Experience: Three years of coding experience as well as following certifications: CDIP, CCDS or CDEO.



    Grade Determinations :
    GS-09 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS): One year of experience equivalent to the next lower grade level.
    GS-8 MRT (Coder) Full Performance Level
    Assignment . This is considered to be the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. 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.

    In addition, applicants must meet the below GS-9 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS) requirements.
    Assignment . For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and range of variety, and be performed by the incumbent at least 25% of the time. 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. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve 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. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere 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.

    In addition to the experience above, the candidate must demonstrate the following KSAs:
    • Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
    • 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;
    • Knowledge of anatomy and physiology, pathophysiology, and pharmacology;
    • Ability to establish and maintain strong verbal and written communication with providers;
    • Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines;
    • 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.
    • Knowledge of severity of illness and risk of mortality indicators; and
    • 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 5005/79 Part II APPENDIX G35

    The full performance level of this vacancy is GS-9.

    Physical Requirements: Light lifting under 15 lbs, reaching above shoulder, use of fingers, both hands required, hearing (aid permitted), working alone, working closely with others, must be mentally and emotionally stable.

    Education

    IMPORTANT: There is no educational substitution at this grade level.



    Additional information

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

    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.

    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 .

    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: The Professional Standards Board (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 eligible for promotion, the board will recommend grade and HR will determine step in accordance with policy.

    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.

    Background checks and security clearance

    Security clearance

    Other

    Drug test required

    No

  • Required Documents

    Required Documents

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

    • 10-2850c VA Application For Associated Health Occupations
    • Resume
    • Resume - Your resume must include: hours worked for all position, FT or PT status, dates employed including month and year, and GS level (if a Federal position). Failure to include this information may result in your disqualification for this position.
    • VA Form 10-2850c Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search .
      • Current federal employees, you must submit a 2019 SF50 that shows grade and step. VA employees may be able to access their SF-50 through eOPF: https://eopf.opm.gov/va/

    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), SF-50's (current/former Federal employees), etc.

    • Cover Letter
    • DD-214/ Statement of Service
    • OF-306
    • 10-2850c VA Application For Associated Health Occupations
    • Other (2)
    • Resume
    • SF-15
    • SF-50/ Notification of Personnel Action
    • Transcript


    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

    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.


9 days ago - source