Medical Records Technician Job Opening at Veterans Affairs, Veterans Health Administration in Northampton, MA

Job Title:Medical Records Technician

Department:Department Of Veterans Affairs

Agency:Veterans Affairs, Veterans Health Administration

Job Announcement Number:631-12-721817MKO

Vacancy Identification Number (VIN): 721817

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. How would you like to become a part of a team providing compassionate care to Veterans?

YOU CAN MAKE A DIFFERENCE

The Medical Center serves over 25,000 patients at its main campus and five community based outpatient clinics in Central and Western Massachusetts. Core missions are primary care, mental health inpatient and outpatient care, and extended care. The Medical Center is engaging employees in a 'Culture of Improvement', utilizing a variety of Process Improvement techniques to improve efficiency of clinical operational functions to the benefit of veterans and staff.

VA offers generous paid time off and benefits. For more information on the Department of Veterans Affairs, go to .

Special Employment Consideration: VA encourages persons with disabilities to apply.

RELOCATION EXPENSES AND/OR INCENTIVES ARE NOT AUTHORIZED

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KEY REQUIREMENTS

• U. S. Citizenship
• Must pass pre-employment examination
• English Language Proficiency required
• Designated and-or Random Drug Testing required
• Background and-or Security Investigation required
• May be required to complete one year probationary trial period

HOURS OF THIS POSITION ARE MON - FRI 8:00 AM - 4:30 PM

GRADE TO BE DETERMINED BY MEDICAL RECORDS TECHNICIAN PROFESSIONAL STANDARDS BOARD (PSB). THE FULL PERFORMANCE LEVEL OF THIS POSITION IS A GS-08. HOWEVER, THE PSB MAY RECOMMEND A LEVEL BELOW THE FULL PERFORMANCE LEVEL BASED ON EDUCATION AND EXPERIENCE.

The VA Central Western Massachusetts Healthcare System is seeking a medical records technician. This position is located in the Health Information Management section of the Business Office. At the full performance level the incumbent is responsible for the assignment of appropriate codes to reflect the treatment provided to patients at the Medical Center. A major component of this station's funding is dependent on the timely, accurate and complete capture of required abstracted data from each inpatient and ambulatory care episode of treatment. The medical center delivers the highest quality tertiary health care to Veterans in hospital and clinic based inpatient and outpatient services including, acute psychiatry; extended care; Nursing Home Care; Physical Rehabilitation; Domiciliary; Home Health; Telemedicine; Community Based Outpatient Clinics and Specialty Care. Through partnerships with Dartmouth Medical School and other academic institutions the Northampton VA Medical Center plays a role in training psychiatry residents and allied health professionals in nursing, social work, optometry, psychology, and other health care programs.

The incumbent will be responsible for the following tasks, and other tasks as assigned:

*Assigns codes to document patient care encounters for healthcare services provided by Northampton, VAMC
*Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include the International Classification of Diseases-Clinical Modification (ICD-9-CM), Current Procedural Terminology (CPT), HCPCS and other classification systems that may be required such as Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
*Captures inpatient and outpatient data through analysis
*Searches patient records to locate documentation justifying code assignment and gathers data
*Ensures completeness and conformance to accepted VA directives and The Joint Commission requirements
*Follows 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
*Adheres to coding guidelines specific to the Veterans Equitable Resources Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs
*Assists facility staff with documentation requirements
*Provides technical support in areas of regulations and policy, coding requirements, documentation requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing to assure maximum reimbursement potential
*Uses the QuadraMed encoder software and trains others on the Quadramed Compliant Coding Module and VIP Workplace
*Establishes primary and secondary diagnosis and procedure codes for billable and non-billable inpatient and outpatient treatment
*Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program
*Meets regularly occurring Inpatient and Outpatient Close-out as well as Inpatient and Contract Nursing Home (CNH) Quarterly Census Close-out deadlines
*Provides data analysis services and performs data validation reviews to ensure accuracy
*Provides coverage to Record Review and Transcription Monitoring

*Other duties as assigned

Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC) is preferred

BASIC REQUIREMENTS:

GRADE DETERMINATIONS:

GS-4

(a) Experience or Education. None beyond basic requirements.

(b) Demonstrated Knowledge, Skills, and Abilitiess

1. Basic knowledge of medical terminology;

2. Basic knowledge of disease processes and human anatomy;

3. Basic knowledge of medical record/health information guidelines, techniques, and procedures;

4. Knowledge of the medical and legal significance of medical records.

(c) Assignment. Employees at this level serve in entry level MRT career development positions in any area of medical records. It is expected that they receive guidance from more experienced staff members for more complex issues, and require daily direct supervision.

GS-5

(a) Experience. In addition to the basic requirements, at least 1 year of experience at the next lower grade level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:

OR,

(b) Education. Successful completion of a baccalaureate degree from an accredited college or university with a major field of study in medical record technology/health information technology or a related degree with courses related to medical record technology sufficient to evidence the core competencies identified.

(c) Demonstrated Knowledge, Skills, and Abilities

1. Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes sufficient to appropriately file, locate, and disclose health information;

2. Ability to correctly apply a practical knowledge of laws and regulations related to the confidentiality of health information and the release of information from medical records;

3. Knowledge of the internal organization of medical records and medical record references and procedures as appropriate to the position.

4. Ability to use health information software appropriate to the position, such as the electronic patient record, record tracking systems, chart deficiency systems, coding and abstracting systems, release of information systems, document scanning technology, electronic spreadsheets, transcription systems, encoder products, electronic encounter forms, database software, etc.

(d) Assignments. Employees at this grade level serve in developmental positions as MRTs in any of the identified specialized areas and receive guidance from more experienced staff members for more complex medical records and/or coding procedures.

GS-6

(a) Experience. One year of experience comparable to the next lower level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:

(b) Demonstrated Knowledge, Skills and Abilities

1. Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record;

2. Ability to navigate efficiently through the paper and electronic medical record to find needed information;

3. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and ability to use judgment in completing assignments with incomplete or inadequate guidelines;

4. If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable;

5. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA);

6. If assigned to a tumor registry position, ability to apply guidelines and standards for the maintenance of an approved tumor registry; and

7. If assigned to a medical coding position, comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), and skill in applying coding knowledge.

(c) Assignments. Employees at this level typically work in any specialty area of medical record/health information. In some instances, they may be assigned lead or supervisory positions when the highest level of non-supervisory MRT work is at a lower level. They receive little guidance from more experienced staff members.

NOTE: In order to be considered a leader, the employee must be responsible to his/her supervisor for ensuring that the work assignments of the other employees of the team are carried out by successfully performing a range of duties which include such duties as distributing and balancing workload,

monitoring the status and progress of work, instructing and answering employee questions, checking employee work, amending or rejecting work not meeting standards, approving leave for a few hours or for emergencies, resolving simple, informal complaints, etc.

GS-7

(a) Experience. One year of experience comparable to the next lower grade level and must fully meet the KSAs at that level including those for tumor registry or coder assignments if applicable. In addition, the candidate must demonstrate the following KSAs:

(b) Assignments. Employees at this level will be assigned to a specific area of medical record/health information (tumor registry, medical coding, or medical records). They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies are described for each type of assignment as follows.

2. Medical Record Technician Coding Positions. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/ health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level. Since coding rules are specific to individual classification systems, knowledge of coding systems other than the one utilized in the position for which the individual is being boarded does not automatically meet the requirements of the position. Generally, to

receive credit for experience, the coder should have performed the type of coding specified as a significant portion of duties on a regular and recurring basis, and provide evidence of the core competencies identified.

a. Demonstrated Knowledge, Skills, and Abilities

(1) Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying coding knowledge to a wide range of specialty areas;

(2) Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements;

(3) Ability to communicate with clinical staff on coding and documentation issues such as recording inpatient and outpatient diagnoses and procedures, the use of encounter forms, the correct sequencing of diagnoses/ procedures, and/or the relationship between health care documentation and code assignment;

(4) Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and

(5) Skill in reviewing and correcting system or processing errors, reviewing transmission reports, and ensuring all assigned episodes are complete and accurate as appropriate to the duties assigned,

PREFERRED CANDIDATES WILL MEET THE GS-08 GRADE LEVEL REQUIREMENTS

(6) GS-8

(a) Experience. One year of experience comparable to the next lower grade level for the appropriate assignment area and must fully meet the KSAs at that level.

(b) Assignments. Employees at this grade level will be assigned to a specific area of medical record/health information, e.g., tumor registry, medical coding, or medical records. They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies for the different assignments are listed with the assignment.

2. Medical Record Technician (Medical Coder) Positions. This is considered to be the full performance level for this assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:

a. Demonstrated Knowledge, Skills, and Abilities

(1) Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;

(2) Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT; and

(3) Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, diagnostic studies and procedures, outpatient encounters, and inpatient professional fees for a highly diversified range of specialties and subspecialties, such as orthopedics, neurosurgery, cardiology, gastroenterology, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE WILL NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

VA Handbook 5005/15, Part II, Appendix G35, Medical Record Technician, dated March 17, 2006.

PHYSICAL REQUIREMENTS: Work is sedentary and typically performed in an office setting with long periods of sitting.

APPLICANTS PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement.) Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Applicants can verify accreditation at the following website: All education claimed by applicants will be verified by the appointing agency accordingly. 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.

Veterans' Preference:

When applying for Federal Jobs, eligible Veterans should claim preference on their application or résumé. Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must complete an SF 15, Application for 10-Point Veteran Preference. Veterans who are still in the service may be granted tentative preference on the basis of information contained in their applications, but they must produce a DD Form 214 or other proof prior to appointment to document entitlement to preference. For more information on Veterans' Preference, please visit .

Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. You may also be evaluated based upon the question responses you provide during a structured interview. In responding to structured interview questions you should be sure to cite specific examples of experience, explain exactly what you did, and the outcome.

Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, thrift savings plan, and participation in the Federal Employees Retirement System. In addition to traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life. For more information please visit us at .

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employees credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave.

To begin the process, click the Apply Online button at the right side of this screen to create an account or log in to your existing USAJOBS account. Follow the prompts to complete the occupational questionnaire. Please ensure you click the Submit My Answers button at the end of the process.

YOU MUST INCLUDE VA FORM 10-2850c IN YOUR APPLICATION PACKAGE TO BE CONSIDERED FOR THIS VACANCY. You may upload the completed form to your USAJOBS or Application Manager account if you apply online. Then you can use the uploaded form again and again when applying for future vacancies. Please see this guide () for more information on uploading and re-using the form in your applications. Other required forms and documents can also be saved in your account and used the same way. Applicants are urged to apply online; this process is much easier and faster.

Note: To return to a previously Saved or Incomplete application, just reapply through your account in USAJOBS. Check your account () to see the status of your application after applying, including any messages that may have been sent to you.

If you cannot apply online:

1. Click the following link to view and print the occupational questionnaire: .
2. Print this 1203FX form to provide your response to the occupational questionnaire: .
3. Fax the completed 1203FX form along with all supporting documents to (478)757-3144. Your 1203FX form must be placed on top of all materials being faxed and will serve as a cover page for your fax transmission.
4. Keep a copy of your fax receipt in case verification is needed.

To fax supporting documents you are unable to upload:

1. Complete this cover page using the following Vacancy ID: 721817. You must use this fax cover sheet in order for your documents to be matched with your online application.
2. Fax your documents to (478)757-3144.

The complete Application Package must be submitted by 11:59 PM (EST) on Thursday, September 20, 2012.

You must provide a complete Application Package which includes:

1. CV or Resume.
2. VA Form 10-2850c - Application for Associated Health Occupations (Available at ) (required).
3. Occupational Questionnaire
4. If prior military service, include all copies of your DD Forms 214 or proof of service (required). Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must also complete and submit an SF 15, Application for 10-Point Veteran Preference (available at ).
5. If currently employed in the VA system, include latest SF-50 - Notification of Personnel Action. (required).
6. OF 306 (required)

NOTE: FAILURE TO SUBMIT REQUIRED DOCUMENTS WILL RESULT IN AN INELIGIBLE RATING.