[Hiring] Medical Records Technician @Ralph H Johnson Department of Veterans Affairs Medical Center

Role Description

This position is in the Health Information Management (HIM) section at the Ralph H. Johnson VA 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

• Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.
• Diagnoses and procedures will be coded utilizing the current edition of:
  • International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS)
  • Current Procedural Terminology (CPT)
  • Healthcare Common Procedure Coding System (HCPCS)
• Coders will follow current published ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, CPT Guidelines, and other established industry standard coding guidance.
• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures.
• Reviews assigned codes from the current version of several coding systems.
• Adheres to accepted coding practices, guidelines, and conventions when validating codes.
• Monitors ever-changing regulatory and policy requirements affecting coded information.
• Assists facility staff with documentation requirements to accurately reflect patient care.
• Expertly searches the patient record to find documentation justifying code assignment.
• Uses a variety of computer applications in day-to-day activities.
• Reviews, analyzes, and reports performance monitors for coding.
• Audits accuracy and completeness of assigned codes for inpatient and outpatient health records.
• Facilitates improved overall quality, completeness, and accuracy of coded data.
• Responsible for performing audits of coded data and communicating results to leadership.

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.
• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens.
• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major in health information technology/management, or related degree.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Persons hired or reassigned to MRT (Coder) positions 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.
• For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity, and be performed by the incumbent at least 25% of the time.

Benefits

• Work Schedule: Monday-Friday 8:00am-4:30pm. Work hours are subject to change based on agency needs.
• Telework: Yes
• Relocation/Recruitment Incentives: No
• Permanent Change of Station (PCS): Not Authorized
• Financial Disclosure Report: Not required

Physical Requirements

• Position is sedentary.
• Duties require extensive use of fingers to perform keyboarding.
• Ability to hear requests by phone and in person.
• Vision must be adequate to read and prepare documents.