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 Medical Records Technician (CDIS) in Middleton, Wisconsin Feel free to browse this and any other job listings and reach out to us with any questions!
Medical Records Technician (CDIS) – Middleton, Wisconsin
Veterans Health Administration, Department of Veterans Affairs
Job ID: 464201Start Date: 06/07/2021End Date: 06/17/2021
To qualify for this position, facility applicants must meet all requirements within 15 days of the closing date of this announcement, 06/17/2021. All non-facility applicants must meet requirements by the closing date of this announcement, 06/17/2021. BASIC REQUIREMENTS: The following are the basic requirements and qualifications for this position at the entry level at the GS-4 grade.
Citizenship: Must be United States Citizen.
English: Must be proficient in basic written and spoken English.
Experience: At least one (1) year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
Education: An associate 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). (TRANSCRIPTS REQUIRED)
Completion of an AHIMA approved coding program: Completion of an AHIMA approved coding program or other intense coding training program of approximately one (1) 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. (CERTIFICATION REQUIRED)
Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following education/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.
(b) Successful completion of a course of 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 MRT Coder.
Certification Requirement: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (CERTIFICATION REQUIRED) Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. GRADE REQUIREMENTS: In addition to the basic requirements above the following is the amount of experience, education and certification required to qualify for a Medical Records Technician (CDIS -Outpatient and Inpatient) at the GS-9 grade level.
Experience: At least one (1) full year of creditable experience equivalent to the journey grade level (GS-8) of an MRT (Coder-Outpatient and Inpatient).
An associate degree or higher, and three years of experience in clinical documentation improvement and candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records. (TRANSCRIPTS REQUIRED)
Mastery level certification through AHIMA or AAPC AND two years of experience in clinical documentation improvement.
Clinical Experience: Experience such as RN, M.D., or DO, AND one year of experience in clinical documentation improvement. Certification Requirement: Applicants at this level must have either a mastery level certification or clinical documentation improvement certification as per the below:
(a) Master Level Certification: Certification is limited to those 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 Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Cordera (COC), Certified Inpatient Coder (CIC).
(b) 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). (CERTIFICATION REQUIRED) IN ADDITION TO REQUIRED EXPERIENCE, EDUCATION AND CERTIFICATION ABOVE, THE CANDIDATE MUST ALSO DEMONSTRATE 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 communications 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. References: VA Handbook 5005/122, Part II, Appendix G57, Medical Record Technician (Coder) Qualification Standards, 12/10/2019. This can be found in the local Human Resources Office.
If you’d like to submit a resume or apply for this position, please contact Premier Veterans at firstname.lastname@example.org. All are free to apply!