Medical Records Technician (Coder-Outpatient and Inpatient)

Summary

This position is located in the Health Information Management (HIM) service line. Medical Record Technicians (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. These coding practitioners analyze and abstract patients' health records - and assign alpha-numeric codes for each diagnosis and procedure.

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
• 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 NOTE: Mastery level certification is required for all positions above the journey level
• however - for clinical documentation improvement specialist assignments - a clinical documentation improvement certification may be substituted for a mastery level certification
• Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• Grade Determinations: To qualify at the GS 8 - applicants must meet the below requirements Experience:One year of creditable experience equivalent to the next lower grade level
• 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 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 outpatient coding - including ambulatory surgical cases - diagnostic studies and procedures - and outpatient encounters - and inpatient facility 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
• 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) 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 8
• The actual grade at which an applicant may be selected for this vacancy is GS 8.
  
  

Duties

• Total Rewards of a Allied Health Professional Duties include but are not limited to: Selects and assigns codes from current versions of ICD-10-CM - ICD-10-PCS - CPT - and HCPCS classification systems to both inpatient and outpatient records Performs comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis - complications/major complications - comorbid/major comorbid conditions - surgery - inpatient professional services - and procedures for accurate assignment of DRGs
• Independently reviews and abstracts clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes Codes all complicated and complex medical/specialty diseases processes - patient injuries - and all medical procedures in a wide range of ambulatory/inpatient settings and specialties Directly consults with the clinical staff for clarification of conflicting - incomplete - or ambiguous clinical data in the health record
• Abstracts - assigns - and sequences 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 Queries clinical staff with documentation requirements to support the coding process Enters and corrects information that has been rejected - when necessary Enters and corrects information that has been rejected - when necessary Ensures audit findings have been corrected and refiled Uses various computer applications to abstract records - assign codes - and record and transmit data Work Schedule: Monday- Friday - 7:00AM-3:30PM EST Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Various pay rates - pay will be set according to locality rate of selectee
• 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) Remote: This is a remote position where you will work from the location listed above
• This position is 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
• Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order
• Functional Statement #: 92946-A