Medical Records Technician (Coder-Inpatient)

Summary

We are seeking motivated and dependable Medical Records Technician (Coder - Inpatient)! This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician based settings

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. The following are the requirements for appointment as a Medical Records Technician (MRT) (Coder) performing medical coding in the Veterans Health Administration (VHA).

Basic Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• English Language Proficiency
• MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• Experience and/or Education Experience
• One 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 information technology/health information management - or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g. - courses in medical terminology - anatomy and physiology - medical coding - and introduction to health records)
• OR - Completion of an AHIMA approved coding program - or other intense coding training program of approximately one 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: Six 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
• 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 six months of experience provided the training program included courses in anatomy - physiology - and health record techniques and procedures
• Also - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder) Certification
• Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either 1 - 2 - or 3 below: Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• 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)
• Creditable Experience
• Experience is only creditable if it is directly related to the position to be filled
• To be creditable - the candidate's experience must have demonstrated the use of knowledge - skills - and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder)
• Quality of Experience
• To be creditable - experience must be documented on the application or resume and verified in an employment reference or through other independent means
• Grade Determinations: Medical Records Technician (Coder-Inpatient) GS-08 Experience
• One year of creditable experience equivalent to the next lower grade level
• This experience may include - but is not limited to: select and assign codes from current versions of ICD CM - PCS - and/or CPT and HCPCS classification systems for inpatient facility and/or professional services
• Review and record documentation to abstract all required medical - surgical - ancillary - demographic - social and administrative data - with minimal guidance from higher level MRTs (Coder)
• Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes
• Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature
• Query clinical staff with documentation requirements to support the coding process
• Use various computer applications to abstract records - assign codes - and record and transmit data
• Ensure audit findings have been corrected and refiled
• Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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
• Ability to accurately perform the full scope of inpatient coding - including inpatient discharges - surgical cases - diagnostic studies and procedures - and inpatient professional services
• 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: Preferred candidates will have at least four or more years of direct coding experience
• Experience in billing is not considered ""equivalent"" Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• The full performance level of this vacancy is GS-08
• Physical Requirements: The work is primarily sedentary
• Typically - the employee may sit comfortably to do the work
• However - there may be some walking
• standing
• bending
• No special physical demands are required to perform the work
• See VA Directive and Handbook 5019 - Employee Occupational Health Service
• See VA Directive and Handbook 5019
  
  

Duties

• Total Rewards of a Allied Health Professional Duties: Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM - PCS - and/or CPT and HCPCS classification systems for inpatient facility and/or professional services
• Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis - complications/major complications - comorbid/major comorbid conditions - surgery - and procedures for accurate assignment of diagnosis related groups (DRG) - and/ or assigning CPT/HCPCS codes for inpatient professional services
• Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes
• Code all complicated and complex medical/specialty diseases processes - patient injuries - and all medical procedures in a wide range of inpatient settings and specialties
• Directly consult with the clinical staff for clarification of conflicting - incomplete - or ambiguous clinical data in the health record
• Abstract - assign - and sequence codes into encoder software to obtain correct DRG - support medical necessity - resolve encoder edits - and ensure codes accurately reflect services rendered
• Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature
• Query clinical staff with documentation requirements to support the coding process
• Enter and correct information that has been rejected - when necessary
• Correct any identified data errors or inconsistencies
• Ensure audit findings have been corrected and refiled
• Use various computer applications to abstract records - assign codes - and record and transmit data
• MRTs (Coder) may be assigned to a single facility or region - such as a consolidated coding unit
• Work Schedule: Monday - Friday - 8:00 am - 4:30 pm EST
• This position requires the candidate to work in the Eastern Time Zone (ET) and maintain a standard business day schedule
• All work - meetings - and collaboration must be conducted during these hours
• Candidates must be available to respond to work-related communications and participate in scheduled activities within this time frame
• Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases
• When setting pay - a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade)
• Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year)
• Selected applicants may qualify for credit toward annual leave accrual - based on prior [work experience] or military service experience
• Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child
• Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: This position is currently authorized for telework - Location negotiable - incumbent must live within 50 mile radius of a VA Medical Center
• to meet the Return to Office Executive Order requirements - selected candidates may be required to Return to Office
• This will be discussed during the interview process
• Virtual: This position is currently designated as remote
• Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces
• The option for remote work will be assessed continuously - and the selected individual may need to return to a VA office if required
• Functional Statement #: 91173-A Permanent Change of Station (PCS): Not Authorized