Total 30 job vacancies by Veterans Health Administration

Duties include:

• Compiles and verifies data, frequently developing worksheets to improve the accuracy and completeness of information. Responsible for working with numerous, different, and unrelated systems.
• Uses personal computer software, including but not limited to Microsoft Office applications (Excel, Word, Outlook, etc.), word processing, internet, and communications and knowledge of computer security.
• Ability to communicate both verbally and in writing with all levels of personnel.
• Researches and communicates with requestor and service line personnel to answer questions and resolve problems concerning obligations, amendments, adjustments, and payments.
• Ability to establish and maintain effective working relationships with and gain the cooperation from all levels of the administrative and professional staff, including supervisors, management officials, department managers and other high level officials and/or representatives of other Federal agencies and private industry.
• Reviews pending items and ensures that follow-up action is taken on all items pending for excessive periods of time. Traces and resolves discrepancies.
• Reviews and analyzes reports, classifies errors, takes corrective action to balance reports, verifies corrected copy and determines the source of processing deficiencies and recommends corrective procedures.
• Analyzes documents for accuracy and authorization, obligations, and payments.
• Responsible for transactions involving the disbursement and receipt of funds, and shows attention to detail when applying appropriations, object classes, and fund control points, to ensure proper deposits and credits.
• Locates, reviews, and interprets guidance including manuals, directives, handbooks, financial policies, decisions.
• Ensures compliance with technical guidance, federal law, and internal controls.

• 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 both inpatient and 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 ensuring 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• 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 the 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.
• Ensures active intra-departmental training program is in place for the HIM staff.
• Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material.
• Facilitates improved overall quality, completeness and accuracy of health record
  documentation.
• 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.
• Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance.
• Provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Analyzes situations or processes and recommends improvements or changes in
  documentation as deemed necessary.
• Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
• Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements.
• Reviews the health record and discusses the case with the clinical staff.
• Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record.
• Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and
  length of stay information by reviewing all clinical documentation, lab results, diagnostic
  information and treatment to ensure documentation reflects severity of illness, acuity
  and resource consumption.
• Participates in clinical rounds and may, where appropriate, offer information on
  documentation, coding rules and reimbursement issues.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices.

**The salary range listed on this announcement only reflects the General Schedule incorporating Rest of U.S. basic pay. Upon selection, the salary will be adjusted to include the locality adjustment for the specific location.**Duties may include, but are not limited to:

• Works collaboratively with VISN programs, services, and interdisciplinary coordinated care team members to provide access to care.
• Routinely reviews computer medication profiles for therapeutic duplication, prescription noncompliance and allergies/drug reactions.
• Processes and submits patient requests for new prescription orders and renewals (including controlled substances) into the computer accurately, thoroughly and in a timely manner.
• Professionally handles issues escalated from team members and follows guidelines to address the issue appropriately.
• Leads the training of new staff.
• Assists with the training, orientation and re-training of employees to Pharmacy Service policies and procedures.
• Responsible for reviewing each subordinate's competencies within applicable areas of assignment on an annual basis.
• Assist in maintaining workflow patterns to ensure patient calls are answered in less than 30 seconds and that less than 5% of calls are abandoned by the patient while ensuring accurate record keeping.
• Assists other pharmacy managers and staff to identify areas of duplication of efforts and develops solutions to streamline processes, reduce waste, save costs and improve patient care.
• Completes additional duties as assigned.

The duties listed above is not inclusive of all the duties that may be associated with this position.

Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced 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.

Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

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. Also applies 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.

Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.

Expertly 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.

Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.

Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.

Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.

Reviews and codes assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.

Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Monday - Friday 8am - 4:30pm
Virtual: This is a Remote position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

This position is located in the Health Information Management (HIM) section at the White River Junction, VT VA Medical Center. MRTs (Coder) 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 alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation.

Duties include but are not limited to:

• Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
• Applies knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
• Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• 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. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Maintains current knowledge of regulatory and policy requirements affecting coded information. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic.
• Reports incorrect documentation or codes in the electronic patient health record. Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment.
• Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Researches references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.
• 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.
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Performs additional duties assigned by management.

• This position is in the Excepted Service.
• This position is a AFGE Bargaining Unit position.

This position is located in the Health Information Management (HIM) section at the White River Junction, VT VA Medical Center. MRTs (Coder) 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 alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation.

Duties include but are not limited to:

• Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
• Applies knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
• Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• 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. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Maintains current knowledge of regulatory and policy requirements affecting coded information. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic.
• Reports incorrect documentation or codes in the electronic patient health record. Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment.
• Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Researches references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.
• 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.
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Performs additional duties assigned by management.

• This position is in the Excepted Service.
• This position is an AFGE Bargaining Unit position.

Major duties include, but may not be limited to:

• Receives telephone calls from Veterans through the automated call distribution system. Answers Veteran inquiries related to process questions.
• Documents all Veteran interactions using progress notes and other reports as needed.
• Uses the highest level of customer service at all times to provide patient education via telephone on the medication refill process.
• Follows-through on all prescription problems by phone or EHR progress note to the provider to avoid Veterans being out of medications.
• Participates in telephone notification of class 1 medication recalls as necessary.
• Guides Veterans on how to return medicine to the pharmacy if needed and how to obtain replacement medications.
• Seeks to solve Veteran's concerns at first contact.
• Independently inputs refill prescriptions into EHR computer system for immediate or mail-out processing.
• Processes batch refill prescription ordering for mail-out processing and ultimate fulfillment of Veteran requests.
• Interacts personally with Veterans or their representatives to assure medication profiles are updated, reviewed, and needed prescriptions items or prosthetics supplies are appropriately processed.
• Accurately fills prescriptions orders by selecting correct product based on label requirements and assures each item is filled and labeled according to all applicable standards.
• Answers questions from pharmacy and non-pharmacy personnel regarding outpatient procedures.
• Performs other duties as required.

Duties Include:

• Applies comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, as well as, the principles and practices of health services and the organization structure to ensure proper code selections
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management (E&M) codes to ensure ethical, accurate, and complete coding
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA
• Assists facility providers 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 requirements, workload, accepted nomenclature and proper sequencing of diagnoses
• Monitors the Physician Query Tracking (PQT) process, providing analysis of coded information and queries sent to providers, makes recommendations, as well as, monitors for potential query opportunities
• Ensures provider documentation is complete and supports the diagnoses and procedures coded
• Directly consults with the providers for clarification of conflicting and or ambiguous clinical data
• Reports the need for improved clinical documentation or ICD codes to the appropriate service chief for training and provider documentation/coding education classes
• Expertly searches the patient health record to find provider documentation justifying ICD code assignment based on an expanded knowledge of the organization and structure of the patient record
• Develops and conducts seminars, workshops, short courses, informational briefings, and conference concerned with health record documentation, educational and functional training requirements to ensure the CDIP objectives are met for clinical and coding staff
• Directly supports physicians, residents, nurses and all other ancillary clinical providers and administrative staff
• Performs documentation audits and coding of providers, provides feedback, and prepares formal reports for meetings, medical providers, nurse managers, Service Chiefs, and Pentad members
• Facilitates improved overall quality, completeness and accuracy of health record documentation, as well as, promotes appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff, and CDIP staff and ensures clinical documentation and services rendered to patients are 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
• As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary
• Compiles, reviews, abstracts, analyzes, and interprets medical data incidental to a variety of patient care and medical treatment activities
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues
• Provides basic education in the areas of clinical documentation, encounters, coding, copy/paste, telephone encounters and resident supervision guidelines
• Assists with reviews including but not limited to external coding audits, Joint Commission, Privacy Compliance and Assurance (PCA), Office of Inspector General (OIG), EPRP, Compliance and VISN reviews

Duties include but not limited to:

• GS-04:
  • Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
  • Applies knowledge of medical record content, medical terminology, anatomy and physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine inpatient services.
  • With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
• GS-05:
  • Maintains current knowledge of regulatory and policy requirements affecting coded information.
  • Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
  • Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic.
• GS-06:
  • Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing.
  • Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment.
  • 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.
• GS-07:
  • 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. Insures provider documentation is complete and supports the diagnoses and procedures coded.
  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
  • Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
• GS-8:
  • Code all inpatient stays (facility and professional fees), all write-in diagnoses and procedures for outpatient encounters and laboratory, radiology, surgical and outpatient encounters that are billed to insurance companies. Codes information from the medial records of patients to generate a clinical care patient care database for the Medical Center. Assures the maintenance and accuracy of the diagnostic and procedural statistics for the facility as well as optimum appropriate reimbursement from the third party payers, by the timely and accurate coding of diagnoses and procedures utilizing the required classification system.
  • Captures data through the Ambulatory Care Data Capture Superbill Form (both printed and electronic), electronic visit notes, the Quadramed/DSS Complaint Coding Module (CCM) and the Patient Treatment File (PTF) in Vista and in Quadramed/DSS. Converts narrative electronic visit notes to ICD, CPT and HCPCS codes.
  • Manually code from the medical record documentation and enter into the appropriate software packages. Inpatient data is captured by the Coders reading the electronic and paper medical record then converting the narrative to ICD, CPT and HCPCS codes.

CDISs must be able to perform all duties of an MRT (Coder-Inpatient). The CDI Specialist serves as a consultant to various medical staff and ad hoc committees related to medical documentation activities, including compliance. They serve on various workgroups and teams as assigned. They are also responsible for reports preparation and presentation of data to the committee(s). Serves as a consultant in the development and updating of Medical Center policy memoranda pertaining to document function and medical record activities. Ensures that medical record documentation activities are consistent with the requirements established by VA manuals and directives and the Joint Commission standards and Scoring Guidelines.

They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. The CDI Specialist analyzes, interprets, and trends findings of quality improvement monitors and prepares monthly/quarterly reports for presentation to the medical staff and/or management. Based on these findings, makes recommendations, and persuades physicians/service chiefs to adopt proposals that result in necessary policy or procedural changes. The CDI Specialist must possess thorough knowledge of medical, terminology, anatomy and physiology and practical knowledge of medical treatment modalities, procedures, surgeries, and disease processes. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. Serves as Subject Matter Expert for HIMS regarding medical record documentation. Develops and maintains collaborative relationships with physicians, service chiefs, and other medical center staff at all organizational levels. Must possess effective interpersonal skills.

Responsible for determining the need for and extent of training medical staff personnel regarding medical record document and requirements. May be required to develop training materials and continuing education programs. Training programs may include legal and ethical documentation practices, Evaluation and Management Code assignment, medical record documentation requirements, etc. In cases where additional medical record documentation is necessary, incumbent advises and/or discusses the issue with the responsible physician(s) via query. Queries sent to clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. Evaluates, monitors, and reports on data from a variety of sources in relation to inpatient and outpatient reimbursement. These sources include Data Validation outputs and data provided from the local VISTA and VA Central Office. Incumbent will conduct monitors, summarize data, and prepare reports in a variety of areas, including a variety of special projects for the HIMS section.

Performs other related duties and responsibilities as assigned by the Chief, HIMS or designee.

Work Schedule: Monday-Friday 8:00AM-4:30PM
Compressed/Flexible: Not Authorized
Virtual: This is a virtual position.
Functional Statement #: 554-60217-0 Medical Records Technician Clinical Document Improvement Specialist (Inpatient) GS-0675-09
Financial Disclosure Report: Not required

CDISs must be able to perform all duties of an MRT (Coder-outpatient). The CDI Specialist serves as a consultant to various medical staff and ad hoc committees related to medical documentation activities, including compliance. They serve on various workgroups and teams as assigned. They are also responsible for reports preparation and presentation of data to the committee(s). Serves as a consultant in the development and updating of Medical Center policy memoranda pertaining to document function and medical record activities. Ensures that medical record documentation activities are consistent with the requirements established by VA manuals and directives and the Joint Commission standards and Scoring Guidelines.

They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. The CDI Specialist analyzes, interprets, and trends findings of quality improvement monitors and prepares monthly/quarterly reports for presentation to the medical staff and/or management. Based on these findings, makes recommendations, and persuades physicians/service chiefs to adopt proposals that result in necessary policy or procedural changes. The CDI Specialist must possess thorough knowledge of medical, terminology, anatomy and physiology and practical knowledge of medical treatment modalities, procedures, surgeries, and disease processes. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. Serves as Subject Matter Expert for HIMS regarding medical record documentation. Develops and maintains collaborative relationships with physicians, service chiefs, and other medical center staff at all organizational levels. Must possess effective interpersonal skills.

Responsible for determining the need for and extent of training medical staff personnel regarding medical record document and requirements. May be required to develop training materials and continuing education programs. Training programs may include legal and ethical documentation practices, Evaluation and Management Code assignment, medical record documentation requirements, etc. In cases where additional medical record documentation is necessary, incumbent advises and/or discusses the issue with the responsible physician(s) via query. Queries sent to clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. Evaluates, monitors, and reports on data from a variety of sources in relation to inpatient and outpatient reimbursement. These sources include Data Validation outputs and data provided from the local VISTA and VA Central Office. Incumbent will conduct monitors, summarize data, and prepare reports in a variety of areas, including a variety of special projects for the HIMS section.

Performs other related duties and responsibilities as assigned by the Chief, HIMS or designee.

Work Schedule: Monday-Friday 8:00AM-4:30PM
Compressed/Flexible: Not Authorized
Virtual: This is a virtual position.
Functional Statement #: 554-60096-A Medical Records Technician Clinical Document Improvement Specialist (outpatient) GS-0675-09
Financial Disclosure Report: Not required

Duties included, but are not limited to:

According to the requirements of the Commission on Cancer, the VA Ann Arbor Healthcare System's Cancer Committee, the National VA Oncology Program and the NCI SEER Programs, incumbent identifies required reportable diseases in this facility's patients through the use of the VISTA Oncology Program.

Thoroughly searches the medical record to identify and code all information pertinent to the patient's diagnosis. This includes demographics, diagnosis, site and histology, diagnostic procedures, extent of disease, and treatment.

Coding assignments may involve highly technical, complex diagnoses/procedures. The incumbent utilizes coding references to ensure that complete and accurate data is collected. In addition, uses specific codes required in a cancer registry, stage of disease, morphology and topography using International Classification of Diseases for Oncology, AJCC Staging Manual, and the FORDS manual.

Independently codes a wide variety of medical diagnostic, therapeutic and surgical procedures. These include:

• 1) Codes stages of disease using American Joint Commission on Cancer staging requirements.
• 2) Analyzes the consistency of coding of registry data, cancer diagnosis, histology, treatment, (including surgical procedures, chemotherapy, immunotherapy, hormonal therapy and radiation therapy).
• 3) Identifies coding discrepancies.
• 4) Facilitates resolution of coding discrepancies by discussion with providers.
• 5) Codes complicated medical records having diagnostic, surgical and therapeutic procedures that are identified as difficult to classify.
• 6) Reviews records to obtain data.
• 7) Enters data obtained from the record into the registry software.
• 8) Analyzes data retrieved and provides the results to health care staff for research, patient care, protocol studies and trends in cancer.

Duties included, but are not limited to:

According to the requirements of the Commission on Cancer, the VA Ann Arbor Healthcare System's Cancer Committee, the National VA Oncology Program and the NCI SEER Programs, incumbent identifies required reportable diseases in this facility's patients through the use of the VISTA Oncology Program.

Thoroughly searches the medical record to identify and code all information pertinent to the patient's diagnosis. This includes demographics, diagnosis, site and histology, diagnostic procedures, extent of disease, and treatment.

Coding assignments may involve highly technical, complex diagnoses/procedures. The incumbent utilizes coding references to ensure that complete and accurate data is collected. In addition, uses specific codes required in a cancer registry, stage of disease, morphology and topography using International Classification of Diseases for Oncology, AJCC Staging Manual, and the FORDS manual.

Independently codes a wide variety of medical diagnostic, therapeutic and surgical procedures. These include:

• 1) Codes stages of disease using American Joint Commission on Cancer staging requirements.
• 2) Analyzes the consistency of coding of registry data, cancer diagnosis, histology, treatment, (including surgical procedures, chemotherapy, immunotherapy, hormonal therapy and radiation therapy).
• 3) Identifies coding discrepancies.
• 4) Facilitates resolution of coding discrepancies by discussion with providers.
• 5) Codes complicated medical records having diagnostic, surgical and therapeutic procedures that are identified as difficult to classify.
• 6) Reviews records to obtain data.
• 7) Enters data obtained from the record into the registry software.
• 8) Analyzes data retrieved and provides the results to health care staff for research, patient care, protocol studies and trends in cancer.

Basic Functions:

• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Applies advanced 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.
• Selects /assigns codes from the current versions of the International Classification of Diseases, Current Procedural Terminology, and/or Healthcare Common Procedure Coding System.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation program
• Monitors ever-changing regulatory and policy requirements affecting coded information
• Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• 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.
• Insures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes
• Expertly 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.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors
• 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.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Conducts re-reviews of codes abstracted for outpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter; adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Reviews and codes assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Basic Functions:

• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Applies advanced 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.
• Selects /assigns codes from the current versions of the International Classification of Diseases, Current Procedural Terminology, and/or Healthcare Common Procedure Coding System.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation program
• Monitors ever-changing regulatory and policy requirements affecting coded information
• Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• 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.
• Insures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes
• Expertly 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.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors
• 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.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Conducts re-reviews of codes abstracted for outpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter; adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Reviews and codes assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.