Medical Records Technician

We are hiring a Medical Records Technician for one of our clients in Temple TX.

Job Description:

Resumes: Provide resumes for all Medical Records Technicians proposed to support this requirement including the 5 FTE assigned to medical records coding services and the 3 FTE assigned to Release of Information (ROI) services. The table below summarizes the required labor categories and associated qualifications.

Job Specification:

• Provide coding services to perform medical records coding validation training in coordination with the auditor and related medical records functions that cover a wide range of medical specialties.
• Staff shall support ROI functions including release processing validation training support in coordination with the ROI Supervisor and compliance with HIPAA guidelines across a wide range of medical specialties.
• Coding Services: Contactor must have knowledge of all VA software VIRR Usage of E&M calculator in VIRR as mandated by the VISN and International Classification of Diseases-Version 10 (ICD-10) for both Diagnosis coding (CM) and Facility Procedure Coding System (PCS).
• Personnel who have credentials such as Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Coding Specialist (CCS) Certified Coding Specialist-Physician (CCS-P) and/or Certified Professional Coder (CPC).

i. Medical Records Technician (Coders-Outpatient (Professional) GS8 Rating): 1 FTE

• A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• All coders are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• proficient in the following code sets: Diagnosis Related Groupings (DRGs) ICD-10 CM ICD-10 PCS CPT and HCPCS coding and be able to provide Facility medical record coding.
• Records Technician (Coders-Outpatient (Professional) GS8 Rating): 2FTE
• A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• All coders are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• proficient in the following code sets: ICD-10 CM CPT and HCPCS coding and be able to provide medical record coding.

iii. two (2) full-time equivalent Team Leads (GS9 Rating) to consist of one (1) Inpatient Team Lead (GS9 Rating) and one (1) Outpatient Team Lead (GS9 Rating)
Outpatient MRT Team Lead

• A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• All Team Leads are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• proficient in the following code sets: ICD-10 CM CPT and HCPCS coding and be able to provide medical record coding. Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate prepare and maintain various reports and analyze data; and may also coordinate assign and monitor workflow.
• They provide assistance with coding inquiries from providers MRTs (Coder) billers and other facility staff.
• The MRT Lead is a supportive role for the Inpatient Coding Supervisor.

b. Inpatient (Facility) MRT Team Lead

• A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• All Team Leads are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• proficient in the following code sets: Diagnosis Related Groupings (DRGs) ICD-10 CM ICD-10 PCS and HCPCS coding and be able to provide medical record coding.

Release of Information Services (ROI): 3 full-time equivalent Medical Record Technician- Release of Information (Client-6 Rating)

• fully trained and competent in use of VA electronic health record systems (VistA CPRS eROI software package).
• personnel shall have a comprehensive knowledge of Federal privacy laws as well as VAs interpretation of these laws as outlined in VHA Directive 1605.01 to appropriately disclose information.
• Personnel must have knowledge of all VA ROI-related software (VistA. eROI CPRS GUI applications) HIPAA and Privacy Act disclosure requirements and VHA performance measures for ROI timeliness.
• Shall have working knowledge of information technology equipment within the ROI section to efficiently assemble the selected documents.
• An understanding of the requirements in VHA Directive 1615 Mandated Utilization of Release of Information (ROI) Plus Software is also essential.
• Should have knowledge of the health record tracking system and the facilitys patient record storage system to determine if paper records exist; the location of the paper records; and the process to request or recall the records if not at the facility (i.e. stored at a federal storage facility).
• At least one year of full-time experience as a Release of Information (ROI) technician or Health Information Technician performing ROI functions in a medical setting is required.

DESCRIPTION OF SERVICES:

• The Contractor shall provide all labor transportation expertise and materials (excluding government-furnished materials as discussed in paragraph 3) to perform coding services and Release of Information (ROI) services as needed to help with coding backlog at the Central Texas Veterans Healthcare System (CTVHCS). The Contractor shall provide coding services to perform medical records coding validation training in coordination with the auditor and related medical records functions that cover a wide range of medical specialties. The Contractor shall process requests for protected health information (PHI) in accordance with applicable federal laws regulations and Veterans Health Administration (VHA) policies and procedures. Contractor staff shall support ROI functions including release processing validation training support in coordination with the ROI Supervisor and compliance with HIPAA guidelines across a wide range of medical specialties.

Coding Services:

The CTVHCS intends on medical coding services as identified in the Performance Work Statement to be performed by a qualified Technical Representative (TR) and a contracted medical coder(s). The Contractor shall provide Contractor personnel who have credentials such as Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Coding Specialist (CCS) Certified Coding Specialist-Physician (CCS-P) and/or Certified Professional Coder (CPC). Coding certification is required at the time of contract award. The Contractor personnel shall maintain full certification during contract period.

• The Contractor personnel will review health care provider medical record coding for completeness and accuracy clarify and correct provider coding as necessary. The Contractor shall query providers via email or VistA Integration Revenue and Reporting (VIRR) using an approved query form for documentation and/or coding clarification to ensure accurate coding reporting. The Contractor will provide required reports and briefings to the designated CTVHCS POC Contracting Officers Technical Representative (COR) as necessary.
• The Contractor shall be responsible to ensure the Contractor employees providing work on this contract are fully trained and completely competent to perform the required work. The Contractor personnel providing coding services may be required to interface with CTVHCS medical claims staff on coding documentation and related billing issues.

Release of Information Services:

The CTVHCS intends ROI services as identified in the PWS to be performed by qualified Release of Information Contractor personnel must show demonstrated experience in ROI services with full understanding of HIPAA 38 U.S.C. 7332 Privacy Act of 1974 and VHA Directive1605.01. Contractor personnel shall maintain Talent Management Systems (TMS2) required training and attend department in-service training throughout the contract period.

• Contractor personnel will review requests for release of information to ensure completeness accuracy and compliance.
• This includes clarifying incomplete requests ensuring requests are HIPAA compliant and querying requestors as needed.
• The contractor will communicate with providers and other qualified healthcare professionals to complete medical forms at the request of Veterans.
• Contractors will utilize VistA eROI software and Social Security Administrations Electronic Records Express (ERE) portal to ensure timely release of requested records.
• The contractor will request archived medical records by submitting a request to the Department of Veterans Affairs Records Center and Vault via the Records Retrieval System as needed.
• Contractors shall produce correspondence in the form of cover letters to communicate with the requestor and update them on the status of their requests.
• The Contractor shall scan all date stamped requests and accompany documentation in the Computerized Patient Record System (CPRS) via VistA Imaging Capture software in a timely manner.
• eROI will be used by the contractor to log and monitor requests for records.
• The contractor will have 20 business days to release routine record requests.
• If additional time is needed to complete the request the contractor shall notify the requestor before the 20th business day.
• At no time shall the contractor exceed 40 business days from the receipt of the request.
• The Contractor personnel shall collaborate with CTVHCS Privacy Office HIM staff and care providers to ensure accurate standardized ROI workflows.
• Contractor shall ensure employees are fully trained and competent in use of VA electronic health record systems (VistA CPRS eROI software package).
• ROI technician may be required to coordinate with other departments (i.e. billing legal and Veterans Benefits Administration) to ensure requests are appropriately processed.

REQUIREMENTS:

• Coding Services: Contactor must have knowledge of all VA software VIRR Usage of E&M calculator in VIRR as mandated by the VISN and International Classification of Diseases-Version 10 (ICD-10) for both Diagnosis coding (CM) and Facility Procedure Coding System (PCS).
• Release of Information Services: Contractor personnel must have knowledge of all VA ROI-related software (VistA. eROI CPRS GUI applications) HIPAA and Privacy Act disclosure requirements and VHA performance measures for ROI timeliness.

QUALIFICATIONS AND EXPERIENCE:

Coding Services:

• The Contractor shall provide one (1) full-time equivalent Medical Records Technician (Coders-Inpatient Facility Procedure Coding System GS8 Rating).
• A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• Contractor employees must also be citizens of the United States and proficient in spoken and written English.
• All coders are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• CTVHCS is a tertiary level of care medical facility accredited by The Joint Commission with a medical school affiliation.
• Its structure is large and complex.
• CTVHCS is an acute care teaching and research institution with approved medical and surgical residency programs as well as other affiliated programs with universities and colleges which also includes a large Domiciliary Unit Ambulatory Surgery Program and an extensive telehealth program.
• Contractor must be proficient in the following code sets: Diagnosis Related Groupings (DRGs) ICD-10 CM ICD-10 PCS CPT and HCPCS coding and be able to provide Facility medical record coding.
• The Contractor shall provide two (2) full-time equivalent Medical Records Technician (Coders-Outpatient (Professional) GS8 Rating).
• A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• Contractor employees must also be citizens of the United States and proficient in spoken and written English.
• All coders are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• CTVHCS is a tertiary level of care medical facility accredited by The Joint Commission with a medical school affiliation.
• Its structure is large and complex. CTVHCS is an acute care teaching and research institution with approved medical and surgical residency programs as well as other affiliated programs with universities and colleges which also includes a large Domiciliary Unit Ambulatory Surgery Program and an extensive telehealth program.
• Contractor must be proficient in the following code sets: ICD-10 CM CPT and HCPCS coding and be able to provide medical record coding
• The Contractor shall provide two (2) full-time equivalent Team Leads (GS9 Rating) to consist of one (1) Inpatient Team Lead (GS9 Rating) and one (1) Outpatient Team Lead (GS9 Rating).
• The Team Leads must meet or exceed the qualifications listed above for the respective coders.

• Outpatient MRT Team Lead A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• Contractor employees must also be citizens of the United States and proficient in spoken and written English.
• All Team Leads are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• CTVHCS is a tertiary level of care medical facility accredited by The Joint Commission with a medical school affiliation. Its structure is large and complex.
• CTVHCS is an acute care teaching and research institution with approved medical and surgical residency programs as well as other affiliated programs with universities and colleges which also includes a large Domiciliary Unit Ambulatory Surgery Program and an extensive telehealth program. Contractor must be proficient in the following code sets: ICD-10 CM CPT and HCPCS coding and be able to provide medical record coding.
• Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate prepare and maintain various reports and analyze data; and may also coordinate assign and monitor workflow.
• They provide input for performance evaluations and hiring.
• They orient and instruct new coding personnel and/or students on coding abstracting and use of the electronic health record and encoder software.
• They ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejections corrected for accurate billing and data collection.
• They monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs.
• They develop coding training materials and present a curriculum encompassing ongoing training initiatives. They provide assistance with coding inquiries from providers MRTs (Coder) billers and other facility staff. The MRT Lead is a supportive role for the Inpatient Coding Supervisor.

• Inpatient (Facility) MRT Team Lead A certified Coder shall have at least one of the following credentials from the American Health Information Management Association (AHIMA): Registered Health Information Technician (RHIT) Certified Coding Specialist (CCS or CCS-P) or Registered Health Information Administrator (RHIA) or American Academy of Professional Coders (AAPC) Certified Professional Coder (CPC).
• Contractor employees must also be citizens of the United States and proficient in spoken and written English.
• All Team Leads are required to have a minimum of three years of continuous coding experience in a facility having a patient population that is equal to or exceeds the VAs current patient population.
• CTVHCS is a tertiary level of care medical facility accredited by The Joint Commission with a medical school affiliation.
• Its structure is large and complex. CTVHCS is an acute care teaching and research institution with approved medical and surgical residency programs as well as other affiliated programs with universities and colleges which also includes a large Domiciliary Unit Ambulatory Surgery Program and an extensive telehealth program.
• Contractor must be proficient in the following code sets: Diagnosis Related Groupings (DRGs) ICD-10 CM ICD-10 PCS and HCPCS coding and be able to provide medical record coding.
• Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate prepare and maintain various reports and analyze data; and may also coordinate assign and monitor workflow.
• They provide input for performance evaluations and hiring.
• They orient and instruct new coding personnel and/or students on coding abstracting and use of the electronic health record and encoder software.
• They ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejections corrected for accurate billing and data collection.
• They monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs.
• They develop coding training materials and present a curriculum encompassing ongoing training initiatives.
• They provide assistance with coding inquiries from providers MRTs (Coder) billers and other facility staff. The MRT Lead is a supportive role for the Inpatient Coding Supervisor.

Release of Information Services:

• The contractor shall provide two (2) full-time equivalent Medical Record Technician- Release of Information (Client-6 Rating).
• ROI provides direct customer service to the Veteran their Personal Representative or third party by providing copies of the Veterans health information when a signed written request is received or upon the Veterans valid authorization to a third party.
• Contractor personnel shall have a comprehensive knowledge of Federal privacy laws as well as VAs interpretation of these laws as outlined in VHA Directive 1605.01 to appropriately disclose information.
• Contractor shall have working knowledge of information technology equipment within the ROI section to efficiently assemble the selected documents.
• They shall have the ability to navigate efficiently and effectively through the paper and electronic patient record as well as to utilize the ROI Plus software to find the requested information.
• An understanding of the requirements in VHA Directive 1615 Mandated Utilization of Release of Information (ROI) Plus Software is also essential.
• Additionally contractor should have knowledge of the health record tracking system and the facilitys patient record storage system to determine if paper records exist; the location of the paper records; and the process to request or recall the records if not at the facility (i.e. stored at a federal storage facility).
• The contractor will need to complete and maintain VA-required proficiency training (HIPAA Privacy Computer Security Privacy and Release of Information training).
• They shall have a thorough knowledge of health record guidelines and procedures to ensure that a complete search for the requested records is accomplished.
• At least one year of full-time experience as a Release of Information (ROI) technician or Health Information Technician performing ROI functions in a medical setting is required.

DOCUMENTATION:
Coding Services: Contractor shall prepare all documentation to meet or exceed established standards of the CTVHCS to include but not limited to: timeliness legibility accuracy content and signature. Only CTVHCS approved abbreviations (which will be provided upon contract start) may be used on documentation of care in the health care record. Contractor personnel providing coding services shall ensure complete patient identifying information is on all documentation that is to become part of a health care record.
Release of Information Services: All documentation shall meet or exceed CTVHCS ROI standards including timeliness legibility accuracy completeness and appropriate signatures. Contractor personnel will use only VHA-approved abbreviations and shall ensure that PHI is protected in all communications and disclosures.
Coder Services
Description of Tasks and Associated Deliverables: