[Hiring] Medical Records Technician (CDIS-Outpatient and Inpatient) @Greater Los Angeles Healthcare System

Role Description

This position is located in the Health Administration Service (HAS), Health Information Management (HIM) section at the VA Greater Los Angeles Healthcare System. MRTs (Coder) are skilled in classifying medical data from patient health records.

Please note that this position is designated as Remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Any selected candidate must live within 50 miles of a VA Medical Center.

Duties include but are not limited to:

• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Assists facility staff with documentation requirements to accurately reflect patient care provided.
• Ensures provider documentation is complete and supports the diagnoses and procedures coded.
• Expertly searches the patient health record to find documentation justifying code assignment.
• Queries medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
• Uses a variety of computer applications in day-to-day activities, including Outlook, Excel, Word, and Access.
• Develops and conducts seminars, workshops, and informational briefings concerning health record documentation.
• Ensures active intra-departmental training program is in place for HIM staff.
• Facilitates improved overall quality, completeness, and accuracy of health record documentation.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes.
• Collaboratively works with professional clinical staff to provide support and education on documentation issues.
• As a technical expert, provides advice and guidance on documentation requirements, liability issues, and patient privacy.

Qualifications

• Citizen of the United States.
• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Associate's degree in health information technology/management or related field with relevant coursework.
• Completion of an AHIMA approved coding program or equivalent intense coding training program.
• Equivalent combinations of creditable experience and education are qualifying.
• Certification through AHIMA or AAPC is required for MRT (Coder) positions.
• Proficient in spoken and written English.

Requirements

• Experience equivalent to the journey grade level of a MRT (Coder-Outpatient).
• Certification at mastery level or Clinical Documentation Improvement Certification.
• Demonstrated knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Ability to collect and analyze data and present results in various formats.
• Knowledge of regulations defining healthcare documentation requirements.
• Extensive knowledge of coding rules and regulations, including ICDCM, PCS, CPT, and HCPCS.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.

Benefits

• Telework available.
• Work schedule: Monday - Friday 7:30am-4:00pm.
• Relocation/Recruitment Incentives: Not Authorized.
• Permanent Change of Station (PCS): Not Authorized.

Physical Requirements

This position is primarily sedentary.