[Hiring] Medical Records Technician (Coder) @William S Middleton Memorial Veterans Hospital

Role Description

This position is located in the Health Information Management (HIM) section at the William S. Middleton Memorial VA Hospital. 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

• 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, and procedures to ensure proper code selection.
• 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 code, abstract, record, and transmit data to the national VA database.
• 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.

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Proficient in spoken and written English.
• One year of creditable experience equivalent to the next lower grade level.
• Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC.
• Must maintain required certification through continuing education.

Requirements

• Experience: 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.

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).
• Up to 12 weeks of paid parental leave after 12 months of employment.