Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS)

Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS)Department of Veterans AffairsVeterans Affairs, Veterans Health AdministrationOverview

##### Open & closing dates

05/27/2019 to 06/17/2019This job will close when we have received 50 applications which

may be sooner than the closing date. Learn more

##### Service

Excepted

##### Pay scale & grade

GS 9

##### Salary

$51,440 to $66,868 per year

##### Appointment type

Permanent

##### Work schedule

Full-TimeLocation1 vacancy in the following location:-Harlingen, TXRelocation expenses reimbursedNoTelework eligibleNo- DutiesSummaryThis position is located in the Health Information Management (HIM)

section of the VA Texas Valley Coastal Bend Health Care System. The

Medical Records Technician (Coder) is responsible for abstracting

medical record data and assigning codes using current clinical

classification systems appropriate for the type of care provided.Learn more about this agencyResponsibilitiesDuties include but are not limited to the following:

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.

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.

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.

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.

Incumbent develops and conducts seminars, workshops, short

courses, informational briefings, and conferences concerned with

health record documentation, educational and functional training

requirements to ensure program objectives are met for clinical

and Health Information Management (HIM) staff.

Collaboratively works with the professional clinical staff and

provides support and education on documentation issues. Assists

in the development of guidelines for data compatibility,

consistency, and monitoring for compliance to improve the

quality for clinical, financial, and administrative data to

ensure that all information is fully documented and supported.

Work Schedule: 8:00 am to 4:30 pm

Financial Disclosure Report: Not requiredTravel RequiredNot requiredSupervisory statusNoPromotion PotentialNone

#### Job family (Series)

0675 Medical Records TechnicianSimilar jobs

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- RequirementsConditions of Employment

You must be a U.S. Citizen to apply for this job

Selective Service Registration is required for males born after

12/31/1959

You may be required to serve a probationary period

Subject to a background/security investigation

Must be proficient in written and spoken English

Selected applicants will be required to complete an online

onboarding process

QualificationsTo qualify for this position, applicants must meet all requirements

by the closing date of this announcement, 06/17/2019.Basic Requirements:

a. 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.)b. Experience and Education (1) Experience. One year of

experience that indicates knowledge of medical terminology and

general understanding of the health record. Six months of the

required one year of experience must have provided the knowledge,

skills and abilities (KSAs) needed to perform MRT work.OR,(2) Education. Two years above high school with a minimum of 12

semester hours directly related to MRT work (e.g., courses in

medical terminology, anatomy & physiology, and introduction to

health records).OR,(3) Experience/Education Combination. Equivalent combinations of

experience and education are qualifying. The following

educational/training substitutions are appropriate for combining

education and experience:(a) Six months of experience that indicates knowledge of medical

terminology and general understanding of 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 medical record techniques and procedures.

Also requires six additional months of experience that indicates

knowledge of medical terminology and general understanding of the

health record.English Language Proficiency. MRTs must be proficient in spoken

and written English as required by 38 U.S.C. 7402(d), and 7407(d).Preferred Experience: RHIA, RHIT, CCS, CDI Credentials,

Outpatient coding experience (multiple discipline), Inpatient coding

experience (multiple discipline), Coding and Documentation

Improvement Training/Teaching experience.Grade Determinations:

In addition to meeting the basic qualifications above, you must

meet the following grade requirements and Knowledge, Skills, and

Abilities (KSAs):(a) Experience. One year of experience equivalent to the next

lower grade level.(b) Demonstrated KSAs. In addition to the experience above, the

candidate must demonstrate the following

KSAs: GS-8

1. Ability to work with a team to provide technical guidance, plan,

organize, and coordinate activities of a medical record function in

order to effectively complete job duties of assignment such as

distributing workload, monitoring the status and progress of work,

monitoring accuracy of work, etc,;

2. Comprehensive knowledge of medical record technology theories,

methods, procedures, and techniques for assigned areas, and

3. Ability to communicate tactfully and effectively, both orally and

in writing, in order to meet program objectives. This may include

preparing reports in various formats and presenting data to various

organizational levels.KSAs: GS-9

1. Knowledge of coding and documentation concepts, guidelines, and

clinical terminology;

2. Ability 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 heath record;

3. Knowledge of anatomy and physiology, pathophysiology, and

pharmacology;

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. Knowledge of coding rules and requirements to include clinical

classification systems (such as current versions of ICD and CPT),

complication or comorbidity/major complication or comorbidity

(CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG)

structure, and Present on Admission (POA) indicators.

7. Knowledge of severity of illness and risk of mortality

indicators; and

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 5005/79 PART II APPENDIX G35, MEDICAL

RECORDS TECHNICIAN QUALIFICATION STANDARDS, GS-675The full performance level of this vacancy is GS-8. The actual grade

at which an applicant may be selected for this vacancy is GS-9.Physical Requirements: Light lifting, under 15 pounds, Light

carrying, under 15 pounds, Use of fingers, Both hands required, Both

eyes requiredEducationIMPORTANT: A transcript must be submitted with your application

if you are basing all or part of your qualifications on education.Note: Only education or degrees recognized by the U.S.

Department of Education from accredited colleges, universities,

schools, or institutions may be used to qualify for Federal

employment. You can verify your education here:

http://ope.ed.gov/accreditation/. If you are using foreign education

to meet qualification requirements, you must send a Certificate of

Foreign Equivalency with your transcript in order to receive credit

for that education. For further information, visit:

http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.Additional informationThis job opportunity announcement may be used to fill additional

vacancies.It is the policy of the VA to not deny employment to those that have

faced financial hardships or periods of unemployment.This position is in the Excepted Service and does not confer

competitive status.VA encourages persons with disabilities to apply. The health-related

positions in VA are covered by Title 38, and are not covered by the

Schedule A excepted appointment authority.Veterans and Transitioning Service Members: Please visit the VA for

Vets site for career-search tools for Veterans seeking employment at

VA, career development services for our existing Veterans, and

coaching and reintegration support for military service members.If you are unable to apply online view the following link for

information regarding an Alternate Application.How You Will Be EvaluatedYou will be evaluated for this job based on how well you meet the

qualifications above.IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE

MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your

application, résumé, C.V., and/or supporting documentation will be

verified. Please follow all instructions carefully. Errors or

omissions may affect consideration for employment.NOTE: The Professional Standards Board (a peer-review group)

will review the selected candidate's education and experience and

recommend the grade and salary at which the candidate will be

placed. For internal selectees eligible for promotion, the board

will recommend grade and HR will determine step in accordance with

policy.Experience refers to paid and unpaid experience, including volunteer

work done through National Service programs (e.g., Peace Corps,

AmeriCorps) and other organizations (e.g., professional;

philanthropic; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and

skills and can provide valuable training and experience that

translates directly to paid employment. You will receive credit for

all qualifying experience, including volunteer experience.Background checks and security clearanceSecurity clearanceOtherDrug test requiredNoPosition sensitivity and riskNon-sensitive (NS)/Low RiskTrust determination processSuitability/Fitness, National security- Required DocumentsTo apply for this position, you must provide a complete Application

Package which includes:

VA 10-2850c Application for Associated Health Occupations

(Required), VBA Compensability Letter (if applicable)

Resume

VA Form 10-2850c Application for Associated Health Occupations can

be found at:

http://www.va.gov/vaforms/searchaction.asp?FormNo=2850&tkey=&Action=Search.The following documents are accepted, and may be required if

applicable to your eligibility and/or qualifications for this

position. Please use this checklist to ensure you have included all

documents required for your application, such as a copy of your

transcript (if using education to qualify), SF-50's (current/former

Federal employees), etc.

Cover Letter

DD-214

VA 10-2850c Application for Associated Health Occupations

(Required), VBA Compensability Letter (if applicable)

Resume

SF-15

Veterans' Preference: When applying for Federal Jobs, eligible

Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or

for Sole Survivor Preference (SSP) in the questionnaire. You must

provide a legible copy of your DD214(s) which shows dates and

character of service (honorable, general, etc.). If you are

currently serving on active duty and expect to be released or

discharged within 120 days you must submit documentation related to

your active duty service which reflects the dates of service,

character of service (honorable, general, etc.), and dates of

impending separation. Additionally, disabled veterans and others

eligible for 10-point preference (such as widows or mothers of

eligible Veterans) must also submit an SF-15 "Application for 10

Point Veteran Preference" with required proof as stated on the form.

Documentation is required to award preference. For more information

on Veterans' Preference, please visit

http://www.fedshirevets.gov/job/vetpref/index.aspx.If you are relying on your education to meet qualification requirements:Education must be accredited by an accrediting institution

recognized by the U.S. Department of Education in order for it to be

credited towards qualifications. Therefore, provide only the

attendance and/or degrees from schools accredited by accrediting

institutions recognized by the U.S. Department of Education.Failure to provide all of the required information as stated in this

vacancy announcement may result in an ineligible rating or may

affect the overall rating.- BenefitsA career with the U.S. Government provides employees with a

comprehensive benefits package. As a federal employee, you and your

family will have access to a range of benefits that are designed to

make your federal career very rewarding. Learn more about federal

benefits.Review our benefitsEligibility for benefits depends on the type of position you hold

and whether your position is full-time, part-time, or intermittent.

Contact the hiring agency for more information on the specific

benefits offered.- How to ApplyAll applicants are encouraged to apply online. To apply for this

position, you must complete the full questionnaire and submit the

documentation specified in the Required Documents section below. The

complete application package must be submitted by 11:59 PM (ET) on

06/17/2019 to receive consideration. To preview the questionnaire

click https://apply.usastaffing.gov/ViewQuestionnaire/10512335.

To begin, click Apply Online to create a USAJOBS account or log

in to your existing account. Follow the prompts to select your

USA JOBS resume and/or other supporting documents and complete

the occupational questionnaire.

Click Submit My Answers to submit your application package.

NOTE: It is your responsibility to ensure your responses and

appropriate documentation is submitted prior to the closing date.To verify your application is complete, log into your USA JOBS

account, https://my.usajobs.gov/Account/Login, select the

Application Status link and then select the more information link

for this position. The Details page will display the status of your

application, the documentation received and processed, and any

correspondence the agency has sent related to this application. Your

uploaded documents may take several hours to clear the virus scan

process. To return to an incomplete application, log into your USA

JOBS account and click Update Application in the vacancy

announcement. You must re-select your resume and/or other documents

from your USA JOBS account or your application will be incomplete.NOTE: Participation in the seasonal influenza program is a

condition of employment and a requirement for all Department of

Veterans Affairs Health Care Personnel (HCP). HCP are individuals

who, during the influenza season, work in VHA locations where

patients receive care or who come into contact with VA patients as

part of their duties. VHA locations include, but are not limited to,

VA hospitals and associated clinics, community living centers

(CLCs), community-based outpatient clinics (CBOCs), domiciliary

units, Vet centers and VA-leased facilities. HCP include all VA

licensed and unlicensed, clinical and administrative, paid and

unpaid, full- and part-time employees, intermittent employees, fee

basis employees, VA contractors, students, researchers, volunteers,

and trainees who work at these facilities. HCPs that are unable to

receive or otherwise decline a flu shot will be expected to wear a

face mask throughout the influenza season.Agency contact informationJacqueline BenavidesPhone956-430-9309 X63909EmailJACQUELINE.BENAVIDES@VA.GOVAddressVA TX Valley Coastal Bend HCS

2701 S 77 Sunshine Strip

Harlingen, TX 78550

USLearn more about this agencyNext stepsOnce your online application is submitted you will receive a

confirmation notification by email. After we receive application

packages (including all required documents) and the vacancy

announcement closes, we will review applications to ensure

qualification and eligibility requirements are met. After the review

is complete, a referral certificate(s) is issued and applicants will

be notified of their status by email. Referred applicants will be

notified as such and may be contacted directly by the hiring office

for an interview. All referred applicants receive a final

notification once a selection decision has been made.You may check the status of your application at any time by logging

into your USA Jobs account and clicking on Applications. Information

regarding your application status can be found in the USAJobs Help

Center.- Fair & TransparentThe Federal hiring process is setup to be fair and transparent.

Please read the following guidance.Equal Employment Opportunity PolicyThe United States Government does not discriminate in employment on

the basis of race, color, religion, sex (including pregnancy and

gender identity), national origin, political affiliation, sexual

orientation, marital status, disability, genetic information, age,

membership in an employee organization, retaliation, parental

status, military service, or other non-merit factor.

Equal Employment Opportunity (EEO) for federal employees & job

applicants

Reasonable Accommodation PolicyFederal agencies must provide reasonable accommodation to applicants

with disabilities where appropriate. Applicants requiring reasonable

accommodation for any part of the application process should follow

the instructions in the job opportunity announcement. For any part

of the remaining hiring process, applicants should contact the

hiring agency directly. Determinations on requests for reasonable

accommodation will be made on a case-by-case basis.A reasonable accommodation is any change to a job, the work

environment, or the way things are usually done that enables an

individual with a disability to apply for a job, perform job duties

or receive equal access to job benefits.Under the Rehabilitation Act of 1973, federal agencies must provide

reasonable accommodations when:

An applicant with a disability needs an accommodation to have an

equal opportunity to apply for a job.

An employee with a disability needs an accommodation to perform

the essential job duties or to gain access to the workplace.

An employee with a disability needs an accommodation to receive

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You can request a reasonable accommodation at any time during the

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New employee probationary period

This job originated on www.usajobs.gov. For the full announcement and to

apply, visit www.usajobs.gov/GetJob/ViewDetails/534810200. Only resumes

submitted according to the instructions on the job announcement listed

at www.usajobs.gov will be considered.