Medical Records Technician (Clinical Documentation Improvement Specialist) Job in Martinsburg, West Virginia – Department of Veterans Affairs

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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 (Clinical Documentation Improvement Specialist) in Martinsburg, West Virginia Feel free to browse this and any other job listings and reach out to us with any questions!

Medical Records Technician (Clinical Documentation Improvement Specialist) – Martinsburg, West Virginia
Veterans Health Administration, Department of Veterans Affairs
Job ID: 497540
Start Date: 08/17/2021
End Date: 08/31/2021

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. English Language Proficiency. MRTs (CDIS) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience and Education: Must meet one of the following: 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; 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); 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; 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: (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 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 (CDIS) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determination: To be eligible for GS-09 consideration the applicant must meet one of the following requirements: One year of creditable experience equivalent to the GS-08 level of a MRT (Coder-Outpatient); 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); Mastery level certification through AHIMA or AAPC AND two years of experience in clinical documentation improvement; Clinical experience such as RN, M.D., or 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. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate ALL of the following KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology. 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. 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 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. 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. 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 G 57, Dated December 10, 2019. The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is a GS-09. Physical Requirements: Time is spent sitting for entering and analyzing data. Mainly sedentary with the ability to lift 5 to 10 lbs. Ability to Respond to providers, co-workers and health care workers through hearing is necessary in the transmitting of patient data. Sight is used to enter, collect and analyze data.

If you’d like to submit a resume or apply for this position, please contact Premier Veterans at abjobs@premierveterans.com. All are free to apply!

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