The United States government is a massive employer, and is always looking for qualified candidates to fill a wide variety of open employment positions in locations across the country. Below you’ll find a Qualification Summary for an active, open job listing from the Department of Veterans Affairs. The opening is for a MED RECORDS TECHNICIAN CODER (CDIS Outpatient and Inpatient) in Bronx, New York Feel free to browse this and any other job listings and reach out to us with any questions!
MED RECORDS TECHNICIAN CODER (CDIS Outpatient and Inpatient) – Bronx, New York
Veterans Affairs, Veterans Health Administration, Department of Veterans Affairs
Job ID: 405548Start Date: 02/09/2021End Date: 02/22/2021
Qualification Summary
Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.
.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. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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 time the 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: 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. Grade Determinations: Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); 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 the definitions section of this standard (paragraph 2g above) for a detailed definition of mastery level certification.OR,Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification. NOTE: See the definitions section of this standard (paragraph 2g and 2h) for a detailed definition of mastery level certification and clinical documentation improvement certification. In addition to the above requirements and certifications, applicants must demonstrate all of the following Knowledge, Skills and Abilities (KSAs). Knowledge of coding and documentation concepts, guidelines, and clinical terminology. 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.
Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
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.
Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS).
Knowledge of 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.
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. Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. (3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. References: VA Handbook, 5005, Part II, Appendix G57.
The full performance level of this vacancy is GS 9.
Physical Requirements: This position is primarily sedentary. Assignment. 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.
If you’d like to submit a resume or apply for this position, please contact Premier Veterans at [email protected]. All are free to apply!
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