U.S. Department of Veterans Affairs
Medical Records Tech (Clinical Documentation Improvement Specialist) (Outpatient
U.S. Department of Veterans Affairs, Washington, District of Columbia, us, 20022
Medical Records Tech (Clinical Documentation Improvement Specialist) (Outpatient and Inpatient)
Join to apply for the
Medical Records Tech (Clinical Documentation Improvement Specialist) (Outpatient and Inpatient)
role at
U.S. Department of Veterans Affairs
Base pay range : $69,923.00/yr – $90,898.00/yr
Summary This position is in the Health Information Management (HIM) section at the Washington DC VA Medical Center. Medical Records Technician (CDIS) are skilled in classifying medical data from patient health records in the hospital setting – and/or physician‑based settings – such as physician offices, group practices, multi‑specialty clinics, and specialty centers. The 2‑page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below.
Qualifications
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 credible experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
Education – Associate’s degree in health information technology/management (or related field) with a minimum of 12 semester hours in health information technology. Include courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records.
Completion of an AHIMA‑approved coding program or similar intensive training of approximately one year that includes courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural coding, and basic CPT coding. The program must lead to eligibility for coding certification and be accredited by a national U.S. Department of Education accreditor.
Experience/Education Combination: Equivalent combinations of credible experience and education qualify. Examples include six months of experience in medical terminology, general understanding of medical coding, and one year above high school with a minimum of six semester hours of health information technology courses. Academic or military training that includes courses in anatomy, physiology, and health record techniques can also be substituted on a month‑for‑month basis for up to six months.
Certification:
Apprentice/Associate Level Certification through AHIMA or AAPC.
Mastery Level Certification through AHIMA or AAPC.
Clinical Documentation Improvement Certification through AHIMA or ACDIS. Note: A CDI certification may be substituted for a mastery level certification.
Grade Determinations: GS‑9 MRT (CDIS) – requires one year of credible experience equivalent to the GS‑8 level or equivalent education and experience. Experience includes the ability to analyze health records for coding, evaluate documentation adequacy, and perform outpatient and inpatient coding with judgment. Additional paths include an associate’s degree with three years of experience in CDI, mastery level certification with two years of experience, or clinical experience with one year of CDI experience and advanced certification.
Knowledge, Skills and Abilities: Demonstrate knowledge of coding rules, clinical terminology, anatomy, physiology, pharmacology, evaluation and management criteria, and VA/ CMS/ Joint Commission regulations. Provide strong verbal and written communication with providers and the ability to conduct continuing education for staff development.
Duties
Review the overall quality and completeness of clinical documentation.
Inpatient CDI focuses on concurrent review while the patient is still in‑house; outpatient CDI focuses on improving documentation prior to coding and billing.
Apply comprehensive knowledge of medical terminology, anatomy, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code selection.
Educate clinical staff on inpatient and outpatient episodes, including admissions, discharges, observation, emergency department/urgent care, and clinic visits.
Prepare and conduct provider education on documentation processes, emphasizing impact on coding, workload, quality measures, reimbursement, and funding.
Adhere to accepted coding practices, guidelines, and conventions for selecting diagnoses, operations, procedures, ancillary services, or evaluation and management codes.
Use computer applications such as Outlook, Excel, Word, and Access daily. Proficient use of health record applications (VistA and CPRS) and encoder product suite is required.
Communicate effectively with providers and stakeholders regarding documentation and coding.
Maintain overall rewards and benefits information as outlined in the full performance level of the vacancy (GS‑9).
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Government Administration
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Get notified about new Medical Records Technician jobs in
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Medical Records Tech (Clinical Documentation Improvement Specialist) (Outpatient and Inpatient)
role at
U.S. Department of Veterans Affairs
Base pay range : $69,923.00/yr – $90,898.00/yr
Summary This position is in the Health Information Management (HIM) section at the Washington DC VA Medical Center. Medical Records Technician (CDIS) are skilled in classifying medical data from patient health records in the hospital setting – and/or physician‑based settings – such as physician offices, group practices, multi‑specialty clinics, and specialty centers. The 2‑page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below.
Qualifications
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 credible experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
Education – Associate’s degree in health information technology/management (or related field) with a minimum of 12 semester hours in health information technology. Include courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records.
Completion of an AHIMA‑approved coding program or similar intensive training of approximately one year that includes courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural coding, and basic CPT coding. The program must lead to eligibility for coding certification and be accredited by a national U.S. Department of Education accreditor.
Experience/Education Combination: Equivalent combinations of credible experience and education qualify. Examples include six months of experience in medical terminology, general understanding of medical coding, and one year above high school with a minimum of six semester hours of health information technology courses. Academic or military training that includes courses in anatomy, physiology, and health record techniques can also be substituted on a month‑for‑month basis for up to six months.
Certification:
Apprentice/Associate Level Certification through AHIMA or AAPC.
Mastery Level Certification through AHIMA or AAPC.
Clinical Documentation Improvement Certification through AHIMA or ACDIS. Note: A CDI certification may be substituted for a mastery level certification.
Grade Determinations: GS‑9 MRT (CDIS) – requires one year of credible experience equivalent to the GS‑8 level or equivalent education and experience. Experience includes the ability to analyze health records for coding, evaluate documentation adequacy, and perform outpatient and inpatient coding with judgment. Additional paths include an associate’s degree with three years of experience in CDI, mastery level certification with two years of experience, or clinical experience with one year of CDI experience and advanced certification.
Knowledge, Skills and Abilities: Demonstrate knowledge of coding rules, clinical terminology, anatomy, physiology, pharmacology, evaluation and management criteria, and VA/ CMS/ Joint Commission regulations. Provide strong verbal and written communication with providers and the ability to conduct continuing education for staff development.
Duties
Review the overall quality and completeness of clinical documentation.
Inpatient CDI focuses on concurrent review while the patient is still in‑house; outpatient CDI focuses on improving documentation prior to coding and billing.
Apply comprehensive knowledge of medical terminology, anatomy, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code selection.
Educate clinical staff on inpatient and outpatient episodes, including admissions, discharges, observation, emergency department/urgent care, and clinic visits.
Prepare and conduct provider education on documentation processes, emphasizing impact on coding, workload, quality measures, reimbursement, and funding.
Adhere to accepted coding practices, guidelines, and conventions for selecting diagnoses, operations, procedures, ancillary services, or evaluation and management codes.
Use computer applications such as Outlook, Excel, Word, and Access daily. Proficient use of health record applications (VistA and CPRS) and encoder product suite is required.
Communicate effectively with providers and stakeholders regarding documentation and coding.
Maintain overall rewards and benefits information as outlined in the full performance level of the vacancy (GS‑9).
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Government Administration
Referrals increase your chances of interviewing at U.S. Department of Veterans Affairs by 2×.
Get notified about new Medical Records Technician jobs in
Washington, DC .
#J-18808-Ljbffr