[Hiring] Lead Medical Records Technician @Clement J Zablocki Veterans Administration Medical Center

Role Description

This position is in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center located in Milwaukee, Wisconsin. 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.

The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Major Duties:

• Advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (CD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Insures provider documentation is complete and supports the diagnoses and procedures coded.
• Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
• Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.

Work Schedule: Monday - Friday 8:00am - 4:30pm

Compressed/Flexible: No available

Telework: Yes

Functional Statement #: 10480F

Relocation/Recruitment Incentives: Not authorized.

Permanent Change of Station (PCS): Not authorized.

PCS Appraised Value Offer (AVO): Not authorized.

Qualifications

• 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.
• Must be a citizen of the United States.
• Must be proficient in spoken and written English.
• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• 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.
• Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Must have a mastery level certification for GS-9 Grade Requirements.
• Must have one year of creditable experience equivalent to the GS-8 grade level MRT (Coder).

Benefits

• The work is sedentary, but may require walking, bending, standing, and/or carrying of light items such as files and manuals.
• The work does not require any special physical effort or ability.