[Hiring] Medical Records Technician @Richard L Roudebush VA Medical Center

Role Description

This position is in the Health Information Management section at the Richard L. Roudebush VA Medical Center. MRTs (Coder) analyze, abstract, and classify medical data from patient health records across hospital and physician-based settings, including offices, group practices, multi-specialty clinics, and specialty centers. They assign ICD, CPT, and HCPCS codes and may also provide staff education on coding and documentation.

Responsibilities

• Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge, also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
• Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff.
• All diagnoses and procedure codes are selected from the current version of the ICD coding system.
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions.
• Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient professional and technical fee encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.
• Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; uses established processes to communicate potential billing issues to Consolidated Patient Account Center (CPAC) staff.
• Codes all identified surgical procedures; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; adds Anesthesia and Pathology codes for all billable surgical cases, which may involve creating the encounters.
• Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay (30+ days) admissions to reflect all patient conditions and care up to the census date or to the requested billing date.
• May be required to review and enter coded data from paid Community Care claims using documentation (e.g., hard-copy claims) obtained from non-VA facilities.
• May code diagnoses for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

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: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of 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.
• Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

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, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Quality of Experience: Experience must be documented on the application or resume and verified in an employment reference or through other independent means.

Benefits

• Competitive salary and regular salary increases.
• 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
• After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
• After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance (many federal insurance programs can be carried into retirement).
• This position is currently authorized for telework - Location negotiable, incumbent must live within 50-mile radius of a VA Medical Center.
• This position is currently designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces.