SUPERVISOR MEDICAL RECORDS TECHNICIAN (Coder)

Full Job Description

This position is located in the Health Information Management (HIM) Service at the Salem VA Medical Center and supervisors outpatient and inpatient coders.

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.

Basic Requirements: Citizenship. Citizen of the United States.

(Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) 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).

(c) 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.

Grade Determinations GS-10: Experience. One year of creditable experience equivalent to the next lower grade level (GS-09). Certification.

Employees at this level must have a mastery level certification. Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: 1.

Ability to perform a full range of supervisory duties, to include recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure duties are completed in an accurate and timely fashion.

2. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 3.

Ability to provide or coordinate staff development and training. 4.

Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers. 5.

Ability to collect and analyze data, identify trends, and present results in various formats. Preferred Experience: Knowledge of and experience in both Inpatient and Outpatient Coding.

References: VA Handbook 5005/122PART II APPENDIX G57 dated December 12, 2019.The full performance level of this vacancy is GS-10.

Physical Requirements: Light lifting, under 15 pounds; Light carrying, under 15 pounds; Reaching above shoulder; use of fingers; Both hands required; Walking (up 0.50 hours); Standing (up 0.50 hours); Sitting for up to 7 hours per day.

Major Duties:

The Supervisory MRT Coder is responsible for supervising outpatient and inpatient-related coding, coding auditor, and Clinical Documentation Integrity (CDI) staff in the Salem VA HCS Coding Unit.

The Supervisory MRT Coder must be able to perform all duties of an MRT Coder.

The Supervisory MRT Coder serves as an expert coding & CDI resource to ensure accuracy and integrity of all inpatient-related coding.

Basic and Supervisory Functions: Performs a full range of supervisory responsibilities to include evaluating the performance of subordinate staff, approving leave requests, identifying educational or training needs, resolving employee complaints and taking disciplinary actions, when necessary.

Informs higher level management of anticipated vacancies or increases in workload.

Recommends employees for promotions, reassignments, recognition of superior performance, retention or release of probationary employees or other changes of assigned personnel.

Makes decisions on the selection of employees for vacant or new positions. Prepares workload and production reports. Reviews code assignments and assists coder in improving their accuracy.

Ensures that regulatory guidelines and current coding conventions are followed. Interacts with healthcare providers to discuss ideas to improve patient care and capture an accurate Case Mix Index.

Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, PowerPoint and Access; competent in use of the health record applications (VistA, CPRS and VistA Imaging) as well as the encoder product suite.

Works alongside the service's ADPAC/PAS to ensure that current versions of all software applications are loaded and functional to the Inpatient Coding Unit staff after any updates or changes.

Interacts with healthcare providers to discuss ideas to improve health record documentation to improve patient care and capture an accurate Case Mix Index.

Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, PowerPoint and Access; competent in use of the health record applications (VistA, CPRS and VistA Imaging) as well as the encoder product suite.

Works alongside the service's ASPAC/PAS to ensure that current versions of all software applications are loaded and functional to the Inpatient Coding Unit staff after any updates or changes.

Works within a team environment; supports staff in meeting goals and deadlines; is flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

Work Schedule: 7:45am to 4:30pm, Monday thru Friday Remote: 100% This position is eligible for remote work and is currently operating under an extension of the Return-to-Office (RTO) mandate.

Please note that remote work eligibility is reviewed on an ongoing basis and does not imply a permanent remote work status until an approved exemption is approved.

Employees in this role may be required to comply with future RTO requirements as determined by agency policy. Functional Statement #: Not Required