Medical Records Technician; Clinical Documentation Improvement Specialist; CDIS

Summary

The Medical Records Technician
- Clinical Documentation Improvement Specialist
- Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS).

The Medical Records Technician
- Clinical Documentation Improvement Specialist
- Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS).

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
• English Language Proficiency
• MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• Experience and Education Experience
• One (1) 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:
  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
• 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)
• Certification
• Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) - (2) - or (3) below:
  Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• NOTE:
  
  Mastery level certification is required for all positions above the journey level
• however - for clinical documentation improvement specialist assignments - a clinical documentation improvement certification may be substituted for a mastery level certification
• Loss of Credential
• Following initial certification - credentials must be…