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

Role Description

This position is in the Health Information Management (HIM) section at the Joseph Maxwell Cleland Atlanta 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.

THIS IS A REMOTE POSITION

Responsibilities

• Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC.
• Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases.
• Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes all identified surgical procedures; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; adds Anesthesia and Pathology codes for all billable surgical cases, which may involve creating the encounters.
• Establishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters following applicable regulations, instructions, and requirements for allowable reimbursement.
• Uses a variety of computer applications in day-to-day activities and duties, such as Microsoft Outlook, Excel, Word, and Teams; competent in use of electronic health record applications as well as the encoder product suite.

Work Schedule: Monday-Friday 7:30am - 4:00pm. Work Schedule is subject to change based on agency need.

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 must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
• Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.
• Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).
• 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 MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Requirements

• Demonstrated Knowledge, Skills, and Abilities:
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation.
• Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity.

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 per year).
• 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.
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).