[Hiring] Medical Records Technician @Central Virginia VA Health Care System

Role Description

This position is located in the Health Information Management Section (HIMS) at the Central Virginia VA Health Care System (CVHCS). MRTs (Coder-Inpatient) are skilled in classifying medical data from patient health records in the hospital and residential settings.

Responsibilities

• Selects and assigns codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• Uses various computer applications to abstract records, assign codes, and record and transmit data.
• Codes all complicated and complex medical/specialty disease processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties.
• Reviews provider health record documentation to ensure it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Performs a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services.
• Independently reviews and abstracts clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstracts, assigns, and sequences codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Queries clinical staff with documentation requirements to support the coding process.
• Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies.
• Ensures audit findings have been corrected and refiled.

Work Schedule

• 8:00 am- 4:30 pm; Monday- Friday (negotiable)
• Telework: Available - per agency policy
• Functional Statement #: 000000
• Permanent Change of Station (PCS): Not Authorized

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Certification:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• 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.

Requirements

• Medical Records Technician (Coder-Inpatient), GS-4: None beyond basic requirements.
• Medical Records Technician (Coder-Inpatient), GS-5:
  • One year of creditable experience equivalent to the next lower grade level; or successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education.
  • Demonstrated Knowledge, Skills, and Abilities:
    • Ability to use health information technology and various office software products used in MRT (Coder) positions.
    • Ability to navigate through and abstract pertinent information from health records.
    • Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
    • Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records.
    • Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
    • Ability to manage priorities and coordinate work to complete duties within required timeframes.
• Medical Records Technician (Coder-Inpatient), GS-6:
  • 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 determine whether health records contain sufficient information for regulatory requirements.
    • Ability to apply laws and regulations on the confidentiality of health information.
    • Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
    • Comprehensive knowledge of current classification systems and skill in applying said classifications.
    • Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators.
• Medical Records Technician (Coder-Inpatient), GS-7:
  • One year of creditable experience equivalent to the next lower grade level.
  • Demonstrated Knowledge, Skills, and Abilities:
    • Skill in applying current coding classifications to a variety of inpatient specialty care areas.
    • Ability to communicate with clinical staff for specific coding and documentation issues.
    • Ability to research and solve coding and documentation related issues.
    • Skill in reviewing and correcting system or processing errors.
    • Ability to abstract, assign, and sequence codes, including CC/MCC and POA indicators.
• Medical Records Technician (Coder-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 inpatient coding.
    • Ability to accurately perform the full scope of inpatient coding.
    • Skill in interpreting and adapting health information guidelines.

Benefits

• For more information on this qualification standard, please visit this link .

Physical Requirements

The work is primarily sedentary. Typically, the employee may sit comfortably to do the work. However, there may be some walking; standing; bending. No special physical demands are required to perform the work.