Total 371 Others level Maintenance / Repair job vacancies in AUT - Remote

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.

The Pharmacy Technician, GS-0661-07, with the Clinical Contact Center is expected to strive to achieve First Contact Resolution (FCR) whenever possible. They are expected to maintain a high degree of accurate productivity and performance while being extremely sensitive to their specific contribution to the overall patient care provided. As required and assigned, the incumbent is expected to accomplish all duties normally performed by general VISN Clinical Contact Center pharmacy technicians at the lower grade level.

Specialized duties, in addition to the generalized duties include, but are not limited to the following:

Medication Management:

• Works collaboratively with VISN programs, services, and interdisciplinary team members to provide access to care and meet the need of Veterans, their family members and/or legal representatives via various available contact modalities to include, but not limited to, telephone calls, secure messaging, chat, text messaging, and video regarding a broad range of topics including medication refills and renewals, basic billing inquiries, and procedural pharmacy activities.
• Routinely reviews medication profiles for therapeutic duplication, prescription non­ compliance, allergies, and drug interactions. Seeks assistance with identified individuals from a Clinical Pharmacist or supervisor for further evaluation, if needed.
• Processes and submits patient requests for new prescription orders and renewal requests, including controlled substances, into the VISN Clinical Contact Center software and/or Electronic Health Record (EHR) accurately, thoroughly, and in a timely manner. Uses approved VISN Clinical Contact Center Pharmacy protocols when appropriate to satisfy patient medication requests.
• Consistently documents patient contact and resolution in VISN Clinical Contact Center software and/or the EHR to include, but not limited to, what was requested, what action was taken, and any other information which may be pertinent during future research. Assists in the documentation of medication variances.
• Assists in training of lower graded technicians and technician students.
• Assists in the completion of workload for other VISN Clinical Contact Center Pharmacy Services in the event of natural disasters, low staffing, or other contingency needs.
• Performs all duties of lower graded technicians, if required.

• Actively and diligently treats all Veterans with respect and utmost dignity. Seeks to resolve Veteran's concerns at first contact independently. When required, refers to other VA resources to assist in the resolution process. Always resolves all Veteran issues in a timely and caring manner with emphasis on providing first contact resolution (FCR).
• Seeks assistance from designated Lead Technician, Clinical Pharmacist or Supervisor when responding to unusual questions or when reasonable attempts to satisfy a caller have been unsuccessful.
• Participates in continuous daily improvement and VISN VA Health Connect initiatives.
• Completes additional duties as assigned.

• Oversee regional preventive medicine and public health services and disease surveillance across the assigned network.
• Direct administrative and public health policy in terms of broadly defined missions and functions and determines their effect on program needs.
• Develop regional preventive medicine operational plans, orders and tasks to accomplish Defense Health Agency mission support requirements.
• subject matter expert in advanced clinical public health care, theories, concepts, principles, and methods to experimental theories and/or new advanced developments to solve complex public health problems.
• Recommend significant changes to or the creation of new public health policies and/or programs to achieve far-reaching impact on long term goals with potential impact on broad agency policy objectives.
• Strategically anticipate future requirements and development of new standards, methods, and techniques and evaluate the impact of these products.
• Serve as the Defense Health Network Public Health Emergency Officer (PHEO) for public health emergency preparedness and response across the assigned area of operations.