Medical Records Technician (Clinical Documentation Improvement Specialist (Outpatient/Inpatient))

Veterans Health Administration • Martinsburg, WV

3d • Onsite

About The Position

This position is located in the Health Information Management section at the Martinsburg VA Medical Center. The Medical Records Technician (Coder), serving as a Clinical Documentation Improvement Specialist for outpatient and inpatient care, reviews health records to improve the quality, completeness, and accuracy of clinical documentation. The role applies knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, health services, and health record structure to support accurate code selection and high-quality healthcare data.

The specialist collaborates with clinical staff through written, verbal, and electronic clarification requests; reviews documentation across inpatient and outpatient care settings; and educates providers and other staff about documentation practices, coding, and the effects of documentation on quality measures, workload, reimbursement, and funding. The role also supports training for HIM staff and other personnel, identifies documentation trends and improvement opportunities, and helps ensure that reported clinical information accurately reflects services provided and outcomes measured.

The full performance level is GS-9. The work schedule is Monday through Friday, 7:00 a.m. to 3:30 p.m. The position is not virtual; ad-hoc telework is indicated. Recruitment or relocation incentives and permanent change-of-station assistance are not authorized.

Requirements

• Meet the basic Medical Records Technician requirements through one of the stated pathways: qualifying experience; an eligible associate degree; completion of an approved or qualifying coding training program; or an allowed combination of experience and education.
• Have one year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure and format; or meet an accepted education or experience/education alternative.
• Hold an applicable certification for MRT (Coder) positions: apprentice/associate-level certification through AHIMA or AAPC, mastery-level certification through AHIMA or AAPC, or Clinical Documentation Improvement certification through AHIMA or ACDIS.
• Be proficient in spoken and written English.
• For the GS-9 grade, meet one of the specified pathways: one year of creditable experience equivalent to the journey grade level of an MRT (Coder—Outpatient and Inpatient); an associate degree or higher plus three years of clinical documentation improvement experience and the specified coursework; mastery-level AHIMA or AAPC certification plus two years of clinical documentation improvement experience; or clinical experience such as RN, M.D., or DO plus one year of clinical documentation improvement experience.
• Be a U.S. citizen, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Complete required background/security investigation, onboarding, and application requirements; comply with the seasonal influenza vaccination requirement for VA health care personnel.
• Serve a two-year trial period.
• Meet the physical requirements referenced in VA Directive and Handbook 5019.

Nice To Haves

• Preferred experience includes one year of creditable experience equivalent to GS-08 and specialized experience facilitating improved documentation quality, education, completeness, and accuracy through interaction with clinical, coding, and associated staff.
• Knowledge of medical terminology, expert-level understanding of inpatient and outpatient medical coding as applied to health records, clinical validation experience, and knowledge of clinical criteria are preferred.
• At least one of the following credentials is required for this position: CIC, CPC, CCS, CCS-P, CDEI, CDIP, RHIT, RHIA, CCDS, or CCDS-O.

Responsibilities

• Review the overall quality and completeness of clinical documentation.
• Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, health services, and health record structure to support appropriate code selection and accurate healthcare data.
• Collaborate with clinical staff through written, verbal, or electronic clarification requests or queries.
• Review clinical documentation and educate clinical staff on inpatient and outpatient episodes of care, including admissions, discharges, observation, emergency department and urgent care encounters, and clinic visits.
• Prepare and conduct provider education on health record documentation processes and the effects of documentation on coding, workload, quality measures, reimbursement, and funding.
• Educate providers on accurate and complete health record documentation, appropriate selection of Evaluation and Management, CPT, and ICD-10 diagnosis codes, and documentation supporting codes to the highest degree of specificity.
• Follow accepted coding practices, guidelines, and conventions when verifying diagnosis, operation, procedure, ancillary, or E/M codes to ensure ethical, accurate, and complete coding.
• Review Veterans Equitable Resource Allocation input on missed documentation opportunities and coordinate provider education with the VERA Coordinator.
• Search patient health records to locate documentation supporting code assignments.
• Use computer applications including Outlook, Excel, Word, and Access, as well as electronic health record applications and encoder and/or CDI products.
• Ensure an active intra-departmental training program is in place for HIM staff.
• Determine and address training needs of other personnel by developing training materials, orienting newly assigned interns and residents, and participating in hospital in-service programs.
• Work with physicians, patient caregivers, and HIM coding staff to improve the quality, completeness, and accuracy of health record documentation and ensure documentation reflects services rendered.
• Provide ongoing education to the patient care team to support accurate clinical information used to measure and report physician and medical center outcomes.
• Identify trends and opportunities to improve clinical documentation.
• Perform other duties as assigned.

Benefits

• Competitive salary and regular salary increases
• 37–50 days of annual paid time off per year, including annual leave, sick leave, and paid Federal holidays
• Potential credit toward annual leave accrual based on prior work or military service, subject to approval
• Up to 12 weeks of paid parental leave after 12 months of employment
• Child care subsidy for eligible full-time employees after 60 days of employment, subject to eligibility and limits
• Traditional federal pension, with five-year vesting
• Federal 401K with up to 5% in contributions by VA
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree