---

Veterans Health Administration is Hiring a Medical Records Technician (Coder- Inpatient) Near Wallops Island, VA

Qualifications:

Basic Requirements:

1. United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

2. English Language Proficiency: Must be proficient in spoken and written English .

3. Experience and Education:

• Experience: 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 technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management; OR
• Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 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:
  • (a) 6 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.
  • (b) 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 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

4. Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either below:

• (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
• (2) Mastery Level Certification through AHIMA or AAPC.
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Grandfathering Provision: May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).


Grade Determinations: Medical Records Technician (Coder-Inpatient)

GS-7

• Experience: 1 year of creditable experience equivalent to the next lower grade level.
• Demonstrated KSAs: In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • i. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
  • ii. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
  • iii. Ability to research and solve coding and documentation related issues.
  • iv. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
  • v. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG.

GS-8

• Experience: 1 year of creditable experience equivalent to the next lower grade level.
• Demonstrated KSAs: In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
  • ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  • iii. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Preferred Experience: Minimum 2 years, full time, inpatient coding experience. Coding for a highly complex, multi-specialty, Acute care hospital which includes coding intensive care unit stays, psychiatric inpatient stays, and inpatient surgical (PCS) coding.

References: VA Handbook 5005/122, PART II, APPENDIX G57, 12/10/2019

The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-7 to GS-8.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

Responsibilities:

Basic Functions include but are not limited to the following:

• Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise.
• 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 and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD-10), ICD-10 Procedural Coding System (PCS), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• 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.
• Ensures 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 in the electronic patient health record.
• 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. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Independently researches references to resolve any questionable code errors. Contacts supervisor as appropriate.
• Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, and Word, competent use of the electric health record applications, and the encoder product suite.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
• 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.

Work Schedule: Monday to Friday, 8:00am to 4:30pm Pacific Standard Time
Virtual: This is a remote position.
Functional Statement #: 03712F/03713F - Medical Record Technician (Coder - Inpatient)
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Job Summary