Total 92 Maintenance / Repair job vacancies in remote wd6 2xx

Duties Include:

• Applies comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, as well as, the principles and practices of health services and the organization structure to ensure proper code selections
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management (E&M) codes to ensure ethical, accurate, and complete coding
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA
• Assists facility providers 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 requirements, workload, accepted nomenclature and proper sequencing of diagnoses
• Monitors the Physician Query Tracking (PQT) process, providing analysis of coded information and queries sent to providers, makes recommendations, as well as, monitors for potential query opportunities
• Ensures provider documentation is complete and supports the diagnoses and procedures coded
• Directly consults with the providers for clarification of conflicting and or ambiguous clinical data
• Reports the need for improved clinical documentation or ICD codes to the appropriate service chief for training and provider documentation/coding education classes
• Expertly searches the patient health record to find provider documentation justifying ICD code assignment based on an expanded knowledge of the organization and structure of the patient record
• Develops and conducts seminars, workshops, short courses, informational briefings, and conference concerned with health record documentation, educational and functional training requirements to ensure the CDIP objectives are met for clinical and coding staff
• Directly supports physicians, residents, nurses and all other ancillary clinical providers and administrative staff
• Performs documentation audits and coding of providers, provides feedback, and prepares formal reports for meetings, medical providers, nurse managers, Service Chiefs, and Pentad members
• Facilitates improved overall quality, completeness and accuracy of health record documentation, as well as, promotes appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff, and CDIP staff and ensures clinical documentation and services rendered to patients are complete and accurate
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis
• As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
• Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary
• Compiles, reviews, abstracts, analyzes, and interprets medical data incidental to a variety of patient care and medical treatment activities
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues
• Provides basic education in the areas of clinical documentation, encounters, coding, copy/paste, telephone encounters and resident supervision guidelines
• Assists with reviews including but not limited to external coding audits, Joint Commission, Privacy Compliance and Assurance (PCA), Office of Inspector General (OIG), EPRP, Compliance and VISN reviews

• Maintains accounts by reviewing documents to verify accounting data as necessary, entering data into the system.
• Prepare reports reflecting the examinations made, discrepancies noted, and the corrective entries required to adjust accounts.
• Reviews and reconciles all third-party payer documents for correct data, on all third-party vouchers for accurate claims number.
• Prepares monthly, quarterly and annual reconciliation and recapitulation of third-party billing to assure that collection, billed data, and the computerized and manual reports are in balance.
• Maintains current documentation and guidelines pertaining to reimbursement activities inappropriate files, binders, etc., and ensures preparation and distribution of copies to all appropriate disciplines.

Duties include but not limited to:

• GS-04:
  • Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
  • Applies knowledge of medical record content, medical terminology, anatomy and physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine inpatient services.
  • With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
• GS-05:
  • Maintains current knowledge of regulatory and policy requirements affecting coded information.
  • Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
  • Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic.
• GS-06:
  • Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing.
  • Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment.
  • 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.
• GS-07:
  • 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.
  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
  • Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
• GS-8:
  • Code all inpatient stays (facility and professional fees), all write-in diagnoses and procedures for outpatient encounters and laboratory, radiology, surgical and outpatient encounters that are billed to insurance companies. Codes information from the medial records of patients to generate a clinical care patient care database for the Medical Center. Assures the maintenance and accuracy of the diagnostic and procedural statistics for the facility as well as optimum appropriate reimbursement from the third party payers, by the timely and accurate coding of diagnoses and procedures utilizing the required classification system.
  • Captures data through the Ambulatory Care Data Capture Superbill Form (both printed and electronic), electronic visit notes, the Quadramed/DSS Complaint Coding Module (CCM) and the Patient Treatment File (PTF) in Vista and in Quadramed/DSS. Converts narrative electronic visit notes to ICD, CPT and HCPCS codes.
  • Manually code from the medical record documentation and enter into the appropriate software packages. Inpatient data is captured by the Coders reading the electronic and paper medical record then converting the narrative to ICD, CPT and HCPCS codes.

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