[Hiring] Medical Record Technician (Coder - Inpatient) @VA Northern California Health Care System

Role Description

This position is in the Health Information Management Section at the VA Northern California Health Care System. Certified Coders classify medical data from patient health records. Seeking candidates with robust inpatient coding experience for a complex, multi-specialty Acute Care Hospital. Expertise in ICU coding, psychiatric inpatient admissions, complex surgical procedures using ICD10-PCS and DRG assignment is required. Experience in high volume, tertiary, or academic hospitals is preferred.

Responsibilities

• Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• Comprehensive review of inpatient documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures using ICD-PCS for accurate assignment of diagnosis-related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services.
• Independently review and abstract clinical data from the inpatient 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 disease processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties.
• Consult directly with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstract, assign, and sequence codes into the encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• 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.
• Maintain a 95% coding accuracy on quality audits. Ensure audit findings have been corrected and refiled.
• 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate diagnosis, operation, procedure, or ancillary code.
• Use various required computer applications to abstract records, assign codes, and record and transmit data.

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

Telework: Not Available

Virtual: This position is Remote 100%

Functional Statement #: 07110F

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): 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.
• Basic Requirements:
• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• 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.
• 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.
• OR Experience/Education Combination: 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.
• Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held.

Grade Determinations

• Medical Records Technician (Coder-Inpatient), GS-8
• Experience: One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities:
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding.
• Ability to accurately perform the full scope of inpatient coding.
• Skill in interpreting and adapting health information guidelines.

Physical Requirements

VA Directive and Handbook 5019, Employee Occupational Health Service.