Medical Records Technician (CDIS-Outpatient and Inpatient)

<p>This position is in the Health Information Management (HIM) section at the Columbia VA Health Care System. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.</p><h3>Major Duties</h3><p>Total Rewards of a Allied Health Professional Duties include, but not limited to: Responsible for reviewing the overall quality and completeness of clinical documentation. Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. The goal of these reviews is to ensure that all conditions monitored, evaluated, assessed and treated, or that impact the patient's care are documented as completely and precisely as possible and supported by the clinical indicators present in the health record. This helps to capture the patient's true risk of mortality (ROM)/severity of illness (SOI), supports resource consumption, and enhances continuity of care. Inpatient COi focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house. Outpatient COi focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education. 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 clinical documentation supports proper code selection and reporting of high-quality healthcare data. Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries. Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits. Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. Documentation must support the care provided as well as the health status of the patient. Any clinical indicators not supported by the patient's condition for the current episode of care or encounter must not be introduced solely to increase financial reimbursement. Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), CPT and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation in the electronic patient health record. Adheres to accepted coding practices, guidelines and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or E/M 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. Work Schedule: Monday - Friday, 8:00am - 4:30pm. Work Schedule is subject to change based on agency need. Recruitment Incentive (Sign-on Bonus): Not Authorized. Permanent Change of Station (Relocation Assistance): Not Authorized. Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer 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) Telework: Not Available. Virtual: This is not a virtual position. Functional Statement #: 61015F. Permanent Change of Station (PCS): Not Authorized.</p><h3>Requirements</h3>You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.<h3>Education</h3>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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.