Medical Records Technician (Coder In/Out Patient)

Full Job Description

This remote Medical Records Technician (Coder-Outpatient and Inpatient) position is in support of the Health Information Management Section (HIMS) of the Business Office Service Line at the Manchester NH VAMC Healthcare system.

Remote Work option is now authorized for this position.

This remote option for this position will be assessed continuously, and if selected as a VA employee you may need to return to work to the nearest VA Office in the future, as determined by the agency policy.

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 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). AND 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 Grade Determinations:GS-04- Experience or Education.

None beyond basic requirements. GS-05 (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR, (b) Education.

Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.

(c) Demonstrated KSAs.

In addition to the experience above, the candidate must demonstrate the following KSAs: Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).

Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.

Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.

Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.

Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-06 (a) Experience.

One year of creditable experience equivalent to the next lower grade level. (b) Demonstrated KSAs.

In addition to the experience above, the candidate must demonstrate 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.

Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes.

This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.

Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).

Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.

Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.

Knowledge of complication or comorbidity/major complication GS-07 (a) Experience. One year of creditable experience equivalent to the next lower grade level. (b) Demonstrated KSAs.

In addition to the experience above, the candidate must demonstrate the following KSAs: Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.

Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.

Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

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-08 (a) Experience.

One year of creditable experience equivalent to the next lower grade level. (b) Demonstrated KSAs.

In addition to the experience above, the candidate must demonstrate 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.

Major Duties:

Total Rewards of a Allied Health Professional Medical Record Technicians (MRT) Coders are responsible for classifying medical data from patient health records in the hospital or physician-based settings such as physician offices, group practices, multispecialty clinics, and specialty centers.

MRTs analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Major duties include but are not limited to: Assigns codes to documented patient care encounters covering the full range of health care services provided.

Adheres to accepted coding practices, guidelines to ensure ethical, accurate, and complete coding. Monitors ever-changing regulatory and policy requirements affecting coded information.

Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data.

Assists facility staff with documentation requirements. Orients and instructs new personnel and/or students in the use of an electronic health record.

Identifies the principal diagnosis and principal procedure for every inpatient discharge and identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group.

Conducts re-reviews of codes abstracted for patient encounters and correct coding as needed to ensure proper patient classification.

Codes inpatient professional fee services for identified inpatient admissions. Reviews and codes assigned fee service Care in the Community patient encounters.

Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Full-Time,40 Hours a Week,Monday-Friday,8:00am-4:30pm, EST. 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, Remote/Virtual: Remote Work option is now authorized for this position.

This remote option for this position will be assessed continuously, and if selected as a VA employee you may need to return to work to the nearest VA Office in the future, as determined by the agency policy.

Functional Statement #: To be determined at the time of selection.

GS-04-F04432,GS-05-F04433,GS-6-F04434,GS-07-F04435,GS-08-F04436 Permanent Change of Station (PCS): Not Authorized Notifications: The full performance level of this vacancy is a GS-08.

The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to a GS-08.

The selectee may be promoted to the full performance level (GS-08) without further competition, when all regulatory qualification, and performance requirements are met.

Selection at a lower grade level does not guarantee promotion to the full performance level. This position is in the Excepted Service. EDRP is not authorized.

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/.

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

Preferred Experience: Ideally an experienced Outpatient and Inpatient Coder who is certified via AHIMA or AAPC. VA experience is preferred but not required.

Teamwork skills, tech savvy, good communicator.