George E. Wahlen Medical Center
Vacancy Identification Number (VIN): 1921805
OUR MISSION: To fulfill President Lincoln’s promise – “To care for him who shall have borne the battle, and for his widow, and his orphan” – by serving and honoring the men and women who are America’s Veterans.
The VA Salt Lake City Health Care System (VASLCHCS) is made up of compassionate employees committed to caring for Veterans whose sacrifices know no limit. We are part of the Rocky Mountain Veterans Integrated Service Network (VISN 19). Our health care system consists of the George E. Wahlen Department of Veteran Affairs Medical Center in Salt Lake City, Utah, and nine community clinics across Utah, Idaho, and Nevada. We provide health care to over 50,000 eligible Veterans across one of the largest geographical areas in VA. We are a teaching hospital, providing a full range of patient care services, holistic medicine as well as education and research in partnership with the University of Utah and other institutions of higher education. Comprehensive health care is provided through our primary care providers and tertiary care is offered in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, and geriatrics. For more information on the Department of Veterans Affairs, go to http://www.vacareers.va.gov/.
VA encourages persons with disabilities to apply. The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
Current VA and/or Federal employees should apply under AS6560-2017-1921817-BU.
This position is located in the Health Information Management Section (HIMS) of the Health Administrative Services at George E. Wahlen VA Hospital. The Medical Record Technician (Clinical Documentation Improvement Specialist) is responsible for the Clinical Documentation Improvement (CDI) program to include reviewing, abstracting, and reporting CDI, and VERA-related information from patient records and data from these records. The duties of this position include but are not limited to:
- Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned medical record documentation;
nsures active intra-departmental training program is in place for the medical records staff; – facilitates improved overall quality, completeness and accuracy of medical record documentation; promotes appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, and HIMS coding staff;
- Provides advice and guidance on a medical records programs;
- Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities;
- Performs admission reviews for specific patient populations to facilitate appropriate documentation; and
- Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices.
Work Schedule: Monday – Friday 8:00 a.m. to 4:30 p.m. ***This is not a remote position.
Functional Statement Title/#:Medical Records Technician (Coder)(CDIS)/000000
- Not Required
- Must pass pre-employment examination
- Must be proficient in written and spoken English
- Designated and-or Random Drug Testing required
- Background and-or Security Investigation required
- Selective Service Registration is required for males born after 12/31/1959.
- U.S. citizenship. Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
- Experience and Education
(1) 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.
(2) 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).
(3) 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 months of experience that indicates knowledge of medical terminology and general understanding of the health record.
- Physical Requirements. See VA Directive and Handbook 5019.
- English Language Proficiency. MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
Preferred Experience: Certification is preferred. Certification is offered by AHIMA as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), or Registered Health Information Technician (RHIT). Certification is offered by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder Apprentice (CPC-A), Certified Professional Coder-Hospital Apprentice (CPC-H-A), Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H). ***Applicant must have inpatient coding experience.
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.
GS-9 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS)
Experience. One year experience equivalent to the next lower grade level (GS-8). Examples of specialized experience would typically include, but are not limited to:
Compiling, reviewing, abstracting, analyzing and interpreting medical data incidental to a variety of patient care and treatment activities; Reviewing the medical record and discussing the case with the clinical staff; Performing admission reviews for specific patient populations to facilitate appropriate clinical documentation criteria and ensures the level of services and acuity of care are accurately reflected in the medical record; Selecting of the principal diagnosis and principal procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set (UHDDS); Assisting in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to insure that all information is fully documented and supported; Facilitating improved overall quality, completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIMS coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.
In addition to the experience listed above, the candidate must demonstrate the following KSAs:
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
- Ability 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 heath record;
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology;
- Ability to establish and maintain strong verbal and written communication with providers;
- Knowledge of regulations that define health care documentation requirements, including The Joint Commission, CMS, and VA guidelines.
- Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators.
- Knowledge of severity of illness and risk of mortality indicators; and
- 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 Appendix G35 Medical Record Technician VA Qualification Standard. This can be found in the local Human Resources Office.
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. Physical Requirements: Thework is primarily sedentary, light lifting, under 15 pounds; light carrying, under 15 pounds; use of fingers, both hands; but may require some walking and standing.
What To Expect Next
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. During our review, if your résumé and application package do not support your questionnaire answers, we will adjust your rating accordingly. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email (if provided); otherwise, applicants will receive a notification letter via the U.S. Postal Service. 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 USAJOBS account and clicking on “Application Status.” For a more detailed update of your status, click on “more information.” Information regarding applicant notification points can be found in the USAJobs Resource Center.
VA offers a comprehensive benefits package. This link provides is an overview of the benefits currently offered: http://www.vacareers.va.gov/why-choose-va/benefits/index.asp.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
This job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
How to Apply
All applicants are encouraged to apply online.
To apply for this position, you must complete the View Occupational Questionnaire and submit the documentation specified in the Required Documents section below.
The complete application package must be submitted by 11:59 PM (EST) on Monday, March 13, 2017 to receive consideration.
1. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USAJOBS resume and/or other supporting documents and complete the occupational questionnaire.
2. 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 USAJOBS 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 USAJOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USAJOBS account or your application will be incomplete.
How You Will Be Evaluated
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.
Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
NOTE: The Professional Standards Board (a peer-review group) will review the selected candidate’s education and experience and recommend the grade and salary at which the candidate will be placed. For internal selectees eligible for promotion, the board will determine grade and HR will determine step in accordance with policy.
All applicants are required to submit the following supporting document type(s):
Applicants may also submit the following supporting document type(s),which may not be required for all applicants:
·Other Veterans Document
Please use this checklist to make sure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), documentation to support Veterans Preference claims, or ICTAP/CTAP documentation (for displaced Federal employees). You will not be contacted for additional information.
Veterans’ Preference: When applying for Federal Jobs, eligible Veterans should claim preference on the Occupational Questionnaire in the section provided and provide a legible copy of your DD214(s) and/or documentation related to your active duty service which shows dates of service, character of service (honorable, general, etc.), or dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 “Application for 10 Point Veterans Preference” with required proof as stated on the form. For more information, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx.
Faxing Applications or Supporting Documents: You are encouraged to apply online. Applying online will allow you to review and track the status of your application. If you are unable to apply online or unable to upload your supporting documents to your online application, follow the directions located at the following site: Fax Options. The Vacancy ID of the job opportunity announcement is 1921805.
NOTE: If you applied online and your application is complete, do not fax the paper application (1203-FX) as this will overwrite your prior online responses and may result in you being found ineligible.
For any questions on the announcement, please contact:
Allison Stanton Phone: (801)584-1284×4440 Email: ALLISON.STANTON@VA.GOV