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Medical Records Technician (Coder Inpatient)
@Veterans Health Administration
[Hiring] Medical Records Technician (Coder Inpatient) @Veterans Health Administration
Apr 01, 2025 - Veterans Health Administration is hiring a remote Medical Records Technician (Coder Inpatient). 💸 Salary: $36,049 per year. 📍Location: USA.
This position serves VISN 4 Consolidated Coding Service Center located at the Lebanon VA Medical Center. MRTs (Coder - Inpatient) 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.
Work Schedule: Monday - Friday 8:00 a.m. to 4:30 p.m.
Telework: Not applicable.
Remote: This is a remote position with a pending national approval for return to office exemption for MRT Coders. The supervisor/service line will keep selected applicant abreast of the status of the pending approval.
Virtual: This is not a virtual position.
Functional Statement #: 000000
Financial Disclosure Report: Not required
Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
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: 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 experience and education are qualifying. The following educational/ training substitutions are appropriate :(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
GS-4
Experience or Education. None beyond basic requirements.
GS-5
Experience. One year of experience equivalent to the next lower grade level or 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.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.)
2. Ability to navigate through and abstract pertinent information from health records
3. Knowledge of the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines
4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient episodes of care based on health record documentation.
5. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guideline
6. Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues.
GS-6
Experience. One year of experience equivalent to the next lower level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and evaluate the adequacy of the documentation
2. 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
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPPA))
4. Ability to accurately apply the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios
5. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation
6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG
GS-7
Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment.
3. Ability to research and solve coding and documentation related issues
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
5. Ability to abstract, assign, and sequence codes, including complication or CC/MCC, and POA indicators to obtain correct MS-DRG
GS-8 Full Performance Level
Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient
2. Ability to accurately perform the full scope of inpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and inpatient professional services
3. 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
References: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Responsibilities
MRTs (Coder - Inpatient) perform the full scope of inpatient coding duties. These coding practitioners analyze and abstract patients' health records and assign alphanumeric codes for each diagnosis and procedure. MRT's possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to inpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. MRT (Coder) may also provide education related to coding and documentation. Duties include, but are not limited to:- Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
- Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
- Consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
- Abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related 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.
- Query clinical staff with documentation requirements to support the coding process.
- Enter and correct information that has been rejected.
- Correct any identified data errors or inconsistencies.
- Ensure audit findings have been corrected and refiled.
- Use various computer applications to abstract records, assign codes, and record and transmit data.
Work Schedule: Monday - Friday 8:00 a.m. to 4:30 p.m.
Telework: Not applicable.
Remote: This is a remote position with a pending national approval for return to office exemption for MRT Coders. The supervisor/service line will keep selected applicant abreast of the status of the pending approval.
Virtual: This is not a virtual position.
Functional Statement #: 000000
Financial Disclosure Report: Not required
Education Requirements
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
Qualifications
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 04/10/2025Basic 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: 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 experience and education are qualifying. The following educational/ training substitutions are appropriate :(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
- Apprentice/Associate Level Certification through AHIMA or AAPC
- Mastery Level Certification through AHIMA or AAPC
- Clinical Documentation Improvement Certification through AHIMA or ACDIS
GS-4
Experience or Education. None beyond basic requirements.
GS-5
Experience. One year of experience equivalent to the next lower grade level or 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.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.)
2. Ability to navigate through and abstract pertinent information from health records
3. Knowledge of the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines
4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient episodes of care based on health record documentation.
5. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guideline
6. Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues.
GS-6
Experience. One year of experience equivalent to the next lower level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and evaluate the adequacy of the documentation
2. 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
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPPA))
4. Ability to accurately apply the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios
5. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation
6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG
GS-7
Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment.
3. Ability to research and solve coding and documentation related issues
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
5. Ability to abstract, assign, and sequence codes, including complication or CC/MCC, and POA indicators to obtain correct MS-DRG
GS-8 Full Performance Level
Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient
2. Ability to accurately perform the full scope of inpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and inpatient professional services
3. 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
References: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
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| 📍 | Be aware of the location restriction for this remote position: USA |
| ‼ | Beware of scams! When applying for jobs, you should NEVER have to pay anything. Learn more. |
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All others
|
Salary
💸
$36,049 per year
|
Remote
Location
USA
|
|
Job Type
full-time
|
Posted
Apr 01, 2025
|
️
| 📍 | Be aware of the location restriction for this remote position: USA |
| ‼ | Beware of scams! When applying for jobs, you should NEVER have to pay anything. Learn more. |
