Medical Record Technician (Coder) Clinical Documentation Improvement Specialist (CDIS)

Clement J. Zablocki VA Medical Center 

Introduction:

This position is within the Health Information Management (HIM) Program of the Medical Information Systems (MIS) Division at the Clement J. Zablocki VA Medical Center, located in Milwaukee, Wisconsin. The Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS) is responsible for performing inpatient medical record reviews, abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Job Description:

  • Responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation.
  • Develops and/or update medical center policy memoranda pertaining to documentation improvement.
  • Serves as technical expert in health record content and documentation requirements.
  • Responsible for performing comprehensive reviews of the health record documentation; developing criteria, collecting data, creating reports, graphing and analyzing results.
  • Obtains appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation.
  • Adheres to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements.
  • Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, and conferences) for all providers.
  • Applies knowledge of ICD-10-CM, ICD-10- PCS, CPT, HCPCS, comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, POA indicators, medical terminology, anatomy & physiology, pathology, pharmacology, diagnostic tests, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
  • Assists facility staff with inpatient documentation requirements to completely and accurately reflect the patient care provided.
  • Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation.
  • Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
  • Works with the professional clinical staff and provides support and education on documentation issues.

Required Qualifications:

U.S. Citizenship: Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified candidates in accordance with chapter 3, section A, paragraph 3g, this part.)

English Language Proficiency: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.

OR

Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).

OR

Combination of Experience and Education: 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 months of experience that indicates knowledge of medical terminology and general understanding of the health record.

In Addition To Meeting The Basic Requirements Listed Above, You Must Meet The Specialized Experience At The GS-9 Level To Qualify For This Position.

Grade Requirements

GS-9 Specialized Experience: Must have at least one full year of specialized experience equivalent to at least the next lower grade level (GS-8) that equipped you with the particular knowledge, skills and abilities to perform successfully the duties of the position. Specialized experience includes: analyzing the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation; reading and understanding the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient; ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Preferred Qualifications:

Certification either through The Association of Clinical Documentation Specialists (Certified Clinical Documentation Specialist-CCDS) or American Health Information Management Association (Certified Documentation Improvement Practitioner-CDIP) is highly desired.

Education Qualifications:

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.

Compensation/Benefits:

For a listing of our outstanding benefits, please visit:  http://www.vacareers.va.gov/why-choose-va/benefits/index.asp

Instructions for Resume Submission:

Please submit your resume, transcripts and all required documents to:

David Konopka
David.Konopka@va.gov
Human Resources Specialist
Clement J. Zablocki VA Medical
5000 W. National Avenue | Building 5
Milwaukee, WI 53215
Phone: 414-384-2000, Ext. 42921
Fax: 414-382-5061