[Hiring] LEAD MEDICAL RECORDS TECHNICIAN @Durham VA Medical Center

Role Description

This position is located in the Health Information Management (HIM) section at the Durham VA 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.

• Assigns codes to documented patient care encounters (inpatient and/or outpatient) covering the full range of health care services provided by the VAMC.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and health services principles for proper code selection.
• Selects and assigns codes from current versions of coding systems including ICD, CPT, and/or HCPCS.
• Monitors regulatory and policy requirements affecting coded information for services provided by the VAMC.
• Performs comprehensive review of patient health records to abstract medical, surgical, ancillary, demographic, social, and administrative data.
• Expertly searches patient health records to find documentation justifying code assignment.

Lead Functions

• Monitors work status and progress, instructs employees in specific tasks, and provides on-the-job training.
• Trains and collaborates with staff to develop and maintain ICD and CPT codes for accurate data capture.
• Participates in technical evaluation and validation of health records for compliance with standards.
• Analyzes and recommends improvements in documentation systems to optimize workload and reimbursement.
• Takes initiative in one-on-one provider training to improve health record documentation.
• Identifies training needs based on productivity and accuracy reports.
• Required to train others on the encoder product suite.

Work Schedule

Monday-Friday 7am - 3:30pm; This is a 100% remote position.

Virtual

This is a virtual position.

Relocation/Recruitment Incentives

Not Authorized

Education Requirements

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.

• Applicants pending completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.
• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• OR an associate's degree from an accredited college or university with a major in health information technology/management.
• OR completion of an AHIMA approved coding program or other intense coding training program.
• OR equivalent combinations of creditable experience and education.

Certification

• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

English Language Proficiency

MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

GRADE DETERMINATIONS AND ASSIGNMENTS

• Lead Medical Records Technician (Coder), GS-9.
• Experience equivalent to the journey grade level of a MRT (Coder) and Mastery level certification through AHIMA or AAPC.
• Employees at this level must have a mastery level certification.

Demonstrated Knowledge, Skills, and Abilities

• Ability to work with a team to provide technical guidance and coordinate activities.
• Advanced knowledge of current coding classification systems and ability to solve complex coding questions.
• Effective communication skills, both orally and in writing.
• Knowledge of training methods and ability to provide training to new coding staff.
• Ability to collect and analyze data and present results.
• Leadership skills, including interpersonal relations and conflict resolution.

Preferred Experience

• Outpatient coder.

Reference

For more information on this qualification standard, please visit VA Qualification Standards .

Physical Requirements

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