Lead Medical Records Technician (Coder-Outpatient and Inpatient)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Tennessee Valley Healthcare System.

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.

These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

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).

These requirements apply to all VHA MRT (Coder) positions in the GS-0675 series.

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.

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 experience: (a) 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.

(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.

Grandfathering Provision.

All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation.

Grade Determinations for Lead Medical Records Technician (Coder), GS-09 Experience.

One year of creditable experience equivalent to the journey grade level GS-8 of a Medical Records Technician (Coder) Certification.

Employees at this level must have a Mastery Level Certification through AHIMA or AAPC. Knowledge, skills, and abilities (KSAs).

In addition to the experience above, you must demonstrate all of the following KSAs: Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc.

Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.

Ability to effectively communicate, both orally and in writing, in order to meet program objectives. Knowledge of training methods and the ability to provide training to new coding staff.

Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.

Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff.

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-09.

Physical Requirements: The work is primarily sedentary.

There is walking, bending and reaching required such as for filing or locating material, and carrying items such as reports, documents, and supplies.

Entering data and word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain.

A portion of each day is spent in the laboratory, sorting and preparing samples for testing, which involves periods of standing. Major Duties:

For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time.

Lead MRTs (Coder) must be able to perform all duties of a MRT (Coder).

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 rejects 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.

Work Schedule: Monday- Friday, 7:30am - 4:00pm 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: Adhoc Virtual: This is not a virtual position.

Functional Statement #: 71375F Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized