Applicants pending the completion of educational or certification/licensure requirements may be referred to and tentatively selected but may not be hired until all requirements are met.
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:
OR
- Education; An Associates Degree from an accredited college or university recognized by the US 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/heath information management (e.g.,, courses in medical terminology, anatomy, physiology, medical coding and introduction to health records (Transcripts Required);
OR
- Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR - Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. 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 US Department of Education accreditor, or comparable international accrediting authority at the time the program was completed (Transcripts Required).
OR
- Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements. The following experience and 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).
- English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 USC 7403(f)
- 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.
May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).
In addition to the basic requirement you must also meet the grade requirement/certification requirement and knowledge skill and abilities (KSAs) listed below:
Grade Determinations for the GS-9 MRT (CDIS Outpatient): Qualified applicants must demonstrate one year of experience equivalent to the next lower grade MRT (Coder-Outpatient GS-8 and demonstrate the additional knowledge, skills and abilities at the MRT (CDIS-Outpatient) GS-9.
GS-9 MRT (CDIS Outpatient)
Experience.
1. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
OR
2. 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
3. Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR4. 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.
Demonstrated KSAs
In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
2. 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;
3. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
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. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD, CPT and HSCPCS. 7. Knowledge of 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.
8. Knowledge of training methods and teaching skills is 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 G57 MEDICAL RECORD TECHNICIAN Qualification Standard.
The full performance level of this vacancy is GS-9.
Physical Requirements: Work is primarily sedentary. Employees generally sit to do the work. There may be some walking, standing, or carrying light items such as patient charts/ records, manuals or files. Employees also extract information from computer systems which requires ability to utilize keyboards or other similar devices.