Role Description

The Medical Records Technician (Clinical Documentation Improvement Specialist - Inpatient) classifies medical data from patient health records in the hospital and/or physician based settings. The coding practitioner analyzes and abstracts patients' health records and assigns alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Reviews overall quality and completeness of clinical documentation.
• Applies comprehensive knowledge of medical terminology, anatomy, and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures.
• Prepares and conducts provider education on documentation processes in the health record.
• Adheres to accepted coding practices, guidelines, and conventions.
• Monitors changing regulatory and policy requirements affecting coded information.
• Expertly searches the patient health record to find documentation justifying code assignment.
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences.

Work Schedule

• Full-Time, 0800-1630 (subject to change)

Pay

• Competitive salary and regular salary increases.
• A higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA.

Paid Time Off

• 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
• Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

Parental Leave

• After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy

• After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement

• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.

Insurance

• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).

Remote

• This position is remote work eligible and is currently exempted from return to office requirements.

Qualifications

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology.
• Ability to collect and analyze data and present results in various formats.
• Ability to establish and maintain strong verbal and written communication with providers.
• Knowledge of regulations that define healthcare documentation requirements.
• Extensive knowledge of coding rules and regulations, including current clinical classification systems.
• Knowledge of severity of illness, risk of mortality, and complexity of care.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.

Preferred Experience

• 3+ years coding experience.

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: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• 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.
• Certification: Persons hired or reassigned to MRT (Coder) positions must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification.

Grade Determination

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