[Hiring] Medical Records Technician (Coder - Inpatient) @Lebanon VA Medical Center

Role Description

This position serves VISN 4 Consolidated Coding Service Center located at the Lebanon VA Medical Center. MRTs (Coder - Inpatient) 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.

MRTs (Coder - Inpatient) perform the full scope of inpatient coding duties. These coding practitioners analyze and abstract patients' health records and assign alphanumeric codes for each diagnosis and procedure. MRT's possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to inpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. MRT (Coder) may also provide education related to coding and documentation. Duties include, but are not limited to:

• Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
• Consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature.
• Query clinical staff with documentation requirements to support the coding process.
• Enter and correct information that has been rejected.
• Correct any identified data errors or inconsistencies.
• Ensure audit findings have been corrected and refiled.
• Use various computer applications to abstract records, assign codes, and record and transmit data.

Work Schedule

8:00 a.m. - 4:30 p.m. Monday - Friday

Pay

• Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

Paid Time Off

• 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 per year). Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

Parental Leave

• After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy

• After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement

• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.

Insurance

• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).

Remote

This is a remote position with a pending national approval for return to office exemption for MRT Coders. The supervisor/service line will keep selected applicant abreast of the status of the pending approval.

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• Education: 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 experience and education are qualifying.

Certification

• Persons hired or reassigned to Medical Record Technician (Coder - Inpatient) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
• Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS

Grade Determinations

• GS-4: None beyond basic requirements.
• GS-5: One year of experience equivalent to the next lower grade level (GS-04) or successful completion of a bachelor's degree from an accredited college or university.
• GS-6: One year of experience equivalent to the next lower grade level (GS-05).
• GS-7: One year of experience equivalent to the next lower grade level (GS-06).
• GS-8: One year of experience equivalent to the next lower grade level (GS-07).