[Hiring] Medical Records Technician (Coder-Inpatient) @Carl T Hayden Veterans' Administration Medical Center

Role Description

This position is located in the Health Information Management (HIM) section at the Phoenix 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.

• Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS.
• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC.
• Patient encounters are often complicated and complex requiring extensive coding expertise.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

Work Schedule: Full-Time, Monday - Friday, 7am - 3:30pm

Virtual: This is a virtual position.

Functional Statement #: 00000

Relocation/Recruitment Incentives: Not Authorized

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.
• Basic Requirements:
• 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 (Coder) must be proficient in spoken and written English.
• Certifications: MRT (Coder) GS-0675 must have either (1), (2), or (3) below:
• (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
• Certified Coding Associate (CCA)
• Certified Professional Coder-Apprentice (CPC-A)
• Certified Outpatient Coding-Apprentice (COC-A)
• (2) Mastery Level Certification through AHIMA or AAPC.
• Certified Coding Specialist - Physician-based (CCS-P)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Certified Professional Coder (CPC)
• Certified Outpatient Coder (COC)
• Certified Inpatient Coder (CIC)
• Certified Coding Specialist (CCS)
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Clinical Documentation Improvement Practitioner (CDIP)
• Certified Clinical Documentation Specialist

Requirements

• 1 year as a Certified MRT (Coder-Inpatient)
• Grade Determinations:
• Medical Records Technician (Coder-Inpatients), GS-4
• (a) Experience or Education - None beyond basic requirements above.
• Medical Records Technician (Coder-Inpatients), GS-5
• (a) Experience: One year of creditable experience equivalent to the next lower grade level ~OR~
• (b) Education: Successful completion of a bachelor's degree from an accredited college or university.
• (c) Demonstrated Knowledge, Skills, and Abilities (KSAs):
• Ability to use health information technology and various office software products used in MRT (Coder) positions.
• Ability to navigate through and abstract pertinent information from health records.
• Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and reporting.
• Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation.
• Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
• Ability to manage priorities and work to complete duties within the required timeframes and the ability to follow up on pending issues.
• Medical Records Technician (Coder-Inpatients), GS-6
• (a) Experience: One year of creditable experience equivalent to the next lower grade level.
• (b) Demonstrated Knowledge, Skills, and Abilities (KSAs):
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
• Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes.
• Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
• Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
• Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation.
• Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).
• Medical Records Technician (Coder-Inpatients), GS-7
• (a) Experience: One year creditable experience equivalent to the next lower grade level.
• (b) Demonstrated Knowledge, Skills, and Abilities (KSAs):
• Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
• Ability to communicate with clinical staff for specific coding and documentation issues.
• Ability to research and solve coding and documentation-related issues.
• Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
• Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain the correct MS-DRG.
• Medical Records Technician (Coder-Inpatients), GS-8
• (a) Experience: One year of creditable experience equivalent to the next lower grade level.
• (b) Demonstrated Knowledge, Skills, and Abilities (KSAs):
• 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

• For more information on this qualification standard, please visit here .
• The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

Physical Requirements

The work is primarily sedentary. There is walking, bending & reaching required, such as for filing or locating material & carrying items such as reports, documents/supplies.