[Hiring] Medical Record Technician @Jerry L Pettis Memorial Veterans Hospital

Role Description

This position is located in the Health Information Management (HIM) section at the VA Loma Linda Medical Center. 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Assigns codes to documented patient care encounters (inpatient 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 as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients.
• 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.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; 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.
• Consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Reports incorrect documentation or codes in the electronic patient health record.
• 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.
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Researches references to resolve any questionable code errors; contacts supervisor as appropriate.
• Utilizes a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (Vista and CPRS) as well as the encoder product suite.
• Ensures current versions of all software applications are loaded and functional after any updates or changes.
• 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.
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

Work Schedule

• Monday - Friday 0730 am - 4:00 pm

Telework

• This is not a virtual position.
• This is a remote position. (The option for remote work will be assessed continuously, and you may need to return to a VA office if required.)

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Experience and Education:
  • 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 that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding.
  • Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Certification: 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.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Requirements

• GS-04 Level: Experience or Education. None beyond basic requirements.
• GS-05 Level: Experience. One year of experience equivalent to the next lower grade (GS-04); OR, Education. 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.
• GS-06 Level: Experience. One year of experience equivalent to the next lower grade (GS-05).
• GS-07 Level: Experience. One year of experience equivalent to the next lower grade (GS-06).
• GS-08 Level: Experience. One year of experience equivalent to the next lower grade (GS-07).

Benefits

• Relocation/Recruitment Incentives: Not Authorized

Company Description

For further information, visit: Department of Education 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: Recognition of Foreign Qualifications .