WaukeganRecruiter Since 2001
the smart solution for Waukegan jobs

Medical Records Technician (Coder) CDIS (Outpatient & Inpatient)

Company: Department of Veterans Affairs
Location: North Chicago
Posted on: June 9, 2021

Job Description:

  • Videos

Videos

  • Duties

Help

Duties

Summary

The Medical Records Technician position is located under the Health Information Management at Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, Illinois. The Captain James A. Lovell Federal Health Care Center (FHCC) is larger than just a single facility, but rather a system of facilities throughout Northeastern Illinois which provide medical and dental services to U.S. Military Veterans, Recruits, Active Duty and eligible beneficiaries.

Learn more about this agency

Responsibilities

The basic functions of the Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) 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.
  • 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.
  • 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: Full-time, Monday through Friday, 7:30am to 4pm

Financial Disclosure Report: Not required

Travel Required

Not required

Supervisory status

No

Promotion Potential

None

  • Job family (Series)

0675 Medical Records Technician

Similar jobs

  • Coders, Health Information
  • Health Information Systems Technicians
  • Health Information Technicians
  • Medical Records And Health Information Technicians
  • Medical Records Specialists
  • Medical Records Technicians

  • Requirements

Help

Requirements

Conditions of Employment

  • You must be a U.S. Citizen to apply for this job
  • Designated and/or random drug testing may be required
  • 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

Qualifications

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: 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-
  • 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:
  • (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 (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.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Preferred experience: 5 years of relatable experience or a combination of experience and education as outlined below.

Grade Determinations for the GS-09 Level - Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)):

  • Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);-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. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification

In addition to the experience above, you must demonstrate the Knowledge, Skills, and Abilities:

  • 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. iv. 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. vi. 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: Occasional standing, walking, carrying, pushing, pulling, lifting (not over 10 lbs); Frequent sitting.

Education

IMPORTANT: 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.

Keywords: Department of Veterans Affairs, Waukegan , Medical Records Technician (Coder) CDIS (Outpatient & Inpatient), Other , North Chicago, Illinois

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Log In or Create An Account

Get the latest Illinois jobs by following @recnetIL on Twitter!

Waukegan RSS job feeds