Job Description (Please follow all instructions carefully)

Summary

This position is located in the Health Information Management (HIM) section at the Salt Lake VA Medical Center. MRTs (CDIS) 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 alphanumeric codes for each diagnosis and procedure.

Overview

Accepting applications

Open & closing dates
Opening and closing dates 11/05/2021 to 09/30/2022
Salary
$53,433 - $69,462 per year
Pay scale & grade
GS 9
Location
1 vacancy in the following location:
- Salt Lake City, UT
  
  Salt Lake City, UT 1 vacancy
Telework eligible
No
Travel Required
Not required
Relocation expenses reimbursed
No
Appointment type
Permanent
Work schedule
Full-time
Service
Competitive
Promotion potential
None
Job family (Series)
0675 Medical Records Technician
Supervisory status
No
Security clearance
Other
Drug test
No
Position sensitivity and risk
Non-sensitive (NS)/Low Risk
Trust determination process
Credentialing

Suitability/Fitness
Announcement number
CBSU-11283077-22-MJP
Control number
621068700

This job is open to

The public

U.S. Citizens, Nationals or those who owe allegiance to the U.S.

Clarification from the agency

All U.S. Citizens

Duties

***This is an OPEN CONTINUOUS ANNOUNCEMENT and will remain open until September 30, 2022. Applications will be accepted on an ongoing basis and qualified candidates will be considered as vacancies become available. Applications will remain on file until September 30, 2022.***

- Reviews overall quality and completeness of clinical documentation.

- Reviews patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDI focuses on improving clinical staff documentation of outpatient encounters.

- Reviews 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 proper code selection.

- Reviews clinical documentation and provides education to clinical staff on 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.

- 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), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensures that the documentation supports the codes selected to the highest degree of specificity.

- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.

- Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.

- Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria 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.

- 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.

- Searches 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 computer 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.

- Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
- Ensures active intra-departmental training program is in place for the HIM staff.

- Determines and meets training needs of extra-departmental professional, para-professional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital.

- Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.

- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.

- Identifies trends and/or opportunities to improve clinical documentation.

- Works with professional clinical staff and provides support and education on documentation issues.

- Conducts daily reviews of all new admissions.

- Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information.

- Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices.

Work Schedule: Monday through Friday 8:00am - 4:30pm
Financial Disclosure Report: Not required

Requirements Conditions of Employment

You must be a U.S. Citizen to apply for this job
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
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP)
Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Department of Veterans Affairs Personnel

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred 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.
English Language Proficiency: To be appointed under authority of 38 U.S.C., chapter 73 or 74, to serve in a direct patient-care capacity in the VHA, applicants must be proficient in written and spoken English.
Experience and Education:
- (1) Experience. 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,
- (2) 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, or a related degree with a minimum of 12 semester hours in health information technology/health information management.
- OR,
- (3) 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;
Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
- (a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional 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.
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 ACIDS
NOTE: Mastery Level Certification is required for ALL positions above the journey Level (GS-08); however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Apprentice level certifications do not qualify.

In addition to the basic requirements, the below qualification requirements must be met at the grade in which you are applying.

Grade Determinations: GS-09
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. See definitions e. and f. below:

e. Predominant Specialty Area - Lead/Supervisory MRT (Coder) whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area being led/supervised
f. Apprentice/Associate Level Certification - This is considered an entry level coding certification and is limited to certification obtained through the American Health information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

In addition to the experience above, the candidate must demonstrate all of the following KSAs:

i.Knowledge of coding and documentation concepts, guidelines, and clinical terminology
ii. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record.
iii. Ability to collect and analyze data and prevent 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
v. 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 ICD, CPT, and HCPCS).
vii. 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.
viii. 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: The majority of work is performed in an office setting, primarily while seated. The position requires some standing, ambulation, bending and carrying of items such as training manuals. In addition, there can be increased stress due to the intensity of a patient/customer complaint or concern.

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.

Additional information

Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

This job opportunity announcement may be used to fill additional vacancies.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

This position is in the Excepted Service and does not confer competitive status.

If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.

Benefits

A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

Benefits

Review our benefits

Required Documents

As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have - whether you're a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you're eligible under their policies.

To apply for this position, you must provide a complete Application Package which includes:

10-2850c
Professional Certification
Resume

VA Form 10-2850c Application for Associated Health Occupations can be found at: https://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf.

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

Cover Letter
DD-214/ Statement of Service
Disability Letter (VA)
10-2850c
Other (2)
Other (3)
Professional Certification
Resume
SF-15
SF-50/ Notification of Personnel Action
Transcript

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

How to Apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 09/30/2022 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/11283077.

To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.

NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.

NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

As required by Executive Order 14043, Federal employees are required to be fully vaccinated against COVID-19 regardless of the employee's duty location or work arrangement (e.g., telework, remote work, etc.), subject to such exceptions as required by law. If selected, you will be required to be vaccinated against COVID-19 and submit documentation of proof of vaccination by November 22, 2021 or before appointment or onboarding with the Department of Veterans Affairs (VA), if after November 22. VA will provide additional information regarding what information or documentation is needed and how you can request a legally required exception from this requirement. Please contact the Human Resources Point of Contact listed at the top of the JOA.

Agency contact information Matthew Phillips Matthew Phillips

Phone

801-582-1565 X4772

Matthew.Phillips4@va.gov

Address

VA SALT LAKE CITY HCS
500 Foothill Drive
Salt Lake City, UT 84148
US

Learn more about this agency

Next steps

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the U SAJobs Help Center.

Fair and Transparent

The Federal hiring process is setup to be fair and transparent. Please read the following guidance.