Clinical Documentation Improvement Specialist (Medical Records Technician) Government - Poplar Bluff, MO at Geebo

Clinical Documentation Improvement Specialist (Medical Records Technician)

CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes Work Schedule:
Monday-Friday 8:
00am - 4:
30pm Financial Disclosure Report:
Not required Basic Requirements:
Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) Experience and Education (1) 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, (2) 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, (3) 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, (4) 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). c. 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. 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:
MRT (CDIS - Inpatient/Outpatient), GS-9 One year of creditable experience equivalent to the GS-8 of a MRT (Coder-inpatient/outpatient) which documents the following KSAs:
Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines. 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; OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Certification. For the GS-9 MRT (CDIS) - Mastery Level Certification IS REQUIRED. Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable, 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). Demonstrated KSAs:
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 G57 Physical Requirements:
Moderate Lifting (15-44 lbs); Moderate Carrying (15-44 lbs); Pulling hand over hand (1 hr); Reaching above shoulder, Both hands required; Walking (2hrs); Standing (4hrs); Repeated bending (2hrs); Near vision correctable at 13 to 16 to Jaeger 1 to 4; Far vision correctable in one eye to 20/20 and to 20/40 in the other; and Sitting (4 hrs).
  • Department:
    0675 Medical Records Technician
  • Salary Range:
    $52,905 to $68,777 per year

Estimated Salary: $20 to $28 per hour based on qualifications.

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