Medical Records Technician (Coder) CDIS (Outpatient & Inpatient)
Company: Department of Veterans Affairs
Location: North Chicago
Posted on: June 9, 2021
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
Learn more about this agency
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
- 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
- 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
- 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
- Uses a variety of window based applications in day to day
activities and duties, such as Outlook, Excel, Word, and
- 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
Financial Disclosure Report: Not required
0675 Medical Records Technician
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
- 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
- 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
- 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
- (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
- (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
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
- 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
- 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
In addition to the experience above, you must demonstrate the
Knowledge, Skills, and Abilities:
- Knowledge of coding and documentation concepts, guidelines, and
- 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
- 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
References: VA Handbook 5005/122, Part II, Appendix G57
Physical Requirements: Occasional standing, walking, carrying,
pushing, pulling, lifting (not over 10 lbs); Frequent sitting.
IMPORTANT: A transcript must be submitted with your application
if you are basing all or part of your qualifications on
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:
Keywords: Department of Veterans Affairs, Waukegan , Medical Records Technician (Coder) CDIS (Outpatient & Inpatient), Other , North Chicago, Illinois
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