[Hiring] Medical Records Technician @Sheridan VA Health Care System

Role Description

This position is located in the Health Information Management (HIM) section at the Sheridan VA Medical Center. Medical Records Technician (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. Coding practitioners analyze and abstract patients health records and assign alpha-numeric codes for each diagnosis and procedure.

• Assigns codes to documented patient care encounters (inpatient and 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 the principles and practices of health services.
• Selects and assigns codes from the current version of several coding systems including ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines, and conventions for ethical, accurate, and complete coding.
• Monitors 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.
• Assists facility staff with documentation requirements to accurately reflect patient care provided.
• Expertly searches the patient health record to find documentation justifying code assignment.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
• Uses various computer applications in day-to-day activities, such as Outlook, Excel, Word, and Access.
• Orients and instructs new personnel and/or students 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.
• Identifies the principal diagnosis and principal procedure for every inpatient discharge.
• Conducts re-reviews of codes abstracted for patient encounters identified by the VERA committee.
• Codes inpatient professional fee services for identified inpatient admissions.
• Establishes primary and secondary diagnosis and procedure codes for outpatient encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system.
• Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census.

Requirements

• Work Schedule: Monday-Friday, 7:30am-4:00pm
• Telework: This position is designated as remote; applicants must live within 50 miles of a VA Medical Center.
• Virtual: This is not a virtual position.
• Functional Statement #: 52684A, 52683A, 52682A, 52681A, 52680A
• Relocation/Recruitment Incentives: Not Authorized
• Permanent Change of Station (PCS): Not Authorized

Qualifications

• Medical Records Technician (Coder-Outpatient and Inpatient), GS-8
• 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 coding.
• Ability to accurately perform the full scope of outpatient and inpatient coding.
• Skill in interpreting and adapting health information guidelines.
• Preferred Experience:
• Minimum of three or more years of direct coding experience.
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Education Requirements

• Completion of an AHIMA approved coding program or equivalent training.
• Equivalent combinations of creditable experience and education are qualifying.