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

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Website Department of Veterans Affairs

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.
  • Experience and Education: 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,
  • 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 (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR 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; OR,
  • Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following 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 6 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).
  • Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
    • 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

Grade Determinations:


(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Inpatient/Outpatient). This experience includes: performing the full scope of inpatient and outpatient coding duties. Selecting and assigning codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to outpatient records. Reviewing and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Coding all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Consulting with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Reviewing provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. Ensuring audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
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)
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

(b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

You must demonstrate the following Knowledge, Skills and Abilities:

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 ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
7. Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and 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 for outpatients.
8. 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, Part II Appendix G57, Medical Records Technician (Coder) Qualification Standard GS-675 Veterans Health Administration.

The full performance level of this vacancy is GS-09.

Physical Requirements: Work is primarily sedentary but requires use of fingers for typing, etc. May require light lifting and carrying (under 15 pounds) and reaching above shoulder.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: . 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: .

Associated topics: ascp, lab, laboratory, microbiology, pathology, sample collection, services, surgical technologist, technician i, technician ii

Tagged as: Ascp, Lab, Laboratory, Microbiology, Pathology, Sample Collection, Services, Surgical Technologist, Technician I, Technician Ii

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