Medical Records Technician (Coder-Outpatient and Inpatient)

Summary

The Tuscaloosa - AL VA Healthcare System is seeking Medical Records Technicians (Coder-Outpatient and Inpatient)! MRT (Coders) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics and specialty centers.

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.

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 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: (a) Six months of creditable experience that indicates knowledge of medical 4 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 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: (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
• Grade Determinations: (1) Medical Records Technician (Coder-Outpatient and Inpatient) - GS-5 (a) Experience
• One year of creditable experience equivalent to the next lower grade level
• OR - (b) Education
• Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university recognized by the U.S. Dept of Education - with a major field of study in health information management or a related degree with a minimum of 24 semester hours in health information management or technology
• (c) Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: i
• Ability to use health information technology and software products used in MRT (Coder) positions (ie - the electronic health record - coding & abstracting software
• ii
• Ability to navigate through and abstract pertinent information from health records
• iii
• Knowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines
• iv
• Ability to apply knowledge of medical terminology - human anatomy/physiology - & disease processes to accurately assign codes to outpatient/ambulatory surgery records - based on health record documentation
• v
• Knowledge of The Joint Commission requirements - Centers for Medicare and Medicaid Services (CMS) - and/or health record documentation guidelines
• vi
• Ability to manage priorities and coordinate work - in order to complete duties within required timeframes - &the ability to follow-up on pending issues
• (2) Medical Records Technician (Coder-Outpatient and Inpatient) - GS-6 (a) Experience
• One year of creditable experience equivalent to the next lower grade level
• (b) Demonstrated Knowledge - Skills - and Abilities
• 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 outpatient coding & evaluate the adequacy of the documentation
• ii
• Ability to determine whether health records contain sufficient information for regulatory requirements - are acceptable as legal documents - are adequate for continuity of patient care - & support the assigned codes
• This includes the ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliable
• iii
• Ability to apply laws and regulations on the confidentiality of health information (ie - Privacy Act - Freedom of Information Act - & HIPAA)
• iv
• Ability to accurately apply the ICD CM - procedure coding system (PCS) Official Conventions & Guidelines for Coding and Reporting - and CPT guidelines to coding scenarios
• v
• Comprehensive knowledge of current classification systems - such as ICD CM - CPT - and HCPCS - & skill in applying said classifications to outpatient episodes of care - and/or inpatient professional services based on health record documentation
• vi
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG
• (3) Medical Records Technician (Coder-Outpatient and Inpatient) - GS-7 (a)Experience
• One year of creditable experience equivalent to the next lower grade level
• (b)Demonstrated Knowledge - Skills - and Abilities
• 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 specialty care areas for outpatient episodes of care and/or inpatient professional services 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 - ensuring the correct sequencing of diagnoses and/or procedures - and verifying the relationship between health record documentation and coder 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
• Please see journey grade level requirements under Education sections.
  
  

Duties

• Total Rewards of a Allied Health Professional This position is located in the Health Information Management (HIM) section at the Tuscaloosa VA Medical Center
• MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics - and specialty centers
• MRT (Coder) may also provide education related to coding and documentation
• Major duties may include - but are not limited to: Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties
• Coding systems include current versions of the International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - 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 evaluation and management (E/M) code to ensure ethical - accurate - and complete coding
• Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs
• Utilizes the facility computer system and software applications to code - abstract - record - and transmit data to the national VA database in Austin
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines
• Research references to resolve any questionable code errors
• contacts a senior coder or supervisor when needed
• 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
• Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays
• also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG)
• Upon patient admission to the Community Living Center/Nursing Home Care Unit - codes the admission diagnosis for use by unit staff
• All diagnoses and procedure codes are selected from the current version of the ICD coding system
• Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty 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
• Uses basic knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery
• receives guidance from experienced coder to interpret instructional notations or to bundle encounters or to identify non-billable encounters
• Work Schedule: Monday-Friday 8AM-4:30PM
• Work schedule subject to change based on agency needs
• Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases 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: Not available Virtual: This is not a virtual position
• Functional Statement #: 60245F - 60246F - 60250F - 60256F Permanent Change of Station (PCS): Not authorized