MED RECORDS TECHNICIAN (CODER)-CDIS Job in Asheville, North Carolina – Department of Veterans Affairs



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 in Asheville, North Carolina Feel free to browse this and any other job listings and reach out to us with any questions!

Veterans Health Administration, Department of Veterans Affairs
Job ID: 496675
Start Date: 08/17/2021
End Date: 09/07/2021

Qualification Summary
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. 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: 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. 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: Mastery level certification is required for all positions above the journey level (GS-08); however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. English Language Proficiency: Proficient in spoken and written English. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to meeting the basic requirements listed above, applicants must meet the grade requirements for GS-09 Medical Records Technician (Clinical Documentation Improvement Specialist – Outpatient and Inpatient). Experience: Applicants must have one year of creditable experience equivalent to GS-08 Medical Records Technician (Coder – Outpatient and Inpatient). Examples of qualifying experience include, but are not limited to: performing the full scope of inpatient and outpatient coding duties; selecting and assigning codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records; performing a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs; performing a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services; independently reviewing and abstracting clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; coding all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties; consulting with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record; abstracting, assigning, and sequencing codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered; reviewing provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature; querying clinical staff with documentation requirements to support the coding process; entering and correcting information that has been rejected, when necessary; correcting any identified data errors or inconsistencies; ensuring audit findings have been corrected and refiled; and using various computer applications to abstract records, assign codes, and record and transmit data; OR An associate’s degree or higher degree 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; OR Clinical experience, such as Registered Nurse (RN), Medical Doctor (MD), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. In addition to the experience above, candidates 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. References: VA Handbook 5005, Part II, Appendix G57, Medical Records Technician (Coder) Qualification Standard Physical Requirements: This position is mainly sedentary.

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