Medical Records Technician (Clinical Documentation Improvement Specialist- CDIS-Outpatient

This position is located within the Health Information Management (HIM) section of the Health Administration Service at the Charlie Norwood VA Medical Center. Medical Records Technicians (Coder) serving as Clinical Documentation Improvement Specialists (CDIS
- Outpatient) are highly skilled in classifying medical data from patient health records across both hospital and physician-based settings, including group practices, multi-specialty clinics, and specialty centers 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.

• 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 experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, and medical coding. The structure and format of a health records .One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
• 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.
• 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.
• 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:
• Six months of creditable experience that indicates knowledge of medical 4 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
• 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 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).
• Clinical experience
  , such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement
• Certification. Employees at this level must have a mastery level certification or a clinical documentation improvement certification :
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

• Grade Determinations
  :
  In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates

• Medical Records Technician (Clinical Documentation…