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

Role Description

This position is located in the Veterans Health Administration (VHA), Southeast Network (VISN 7), VA Augusta Health Care System in Augusta, Georgia located in the Health Information Management Section (HIMs) of Health Administration Service (HAS). 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.

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.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures for proper code selection.
• Selects and assigns codes from the current version of several coding systems, including ICD, CPT, and HCPCS.
• Adheres to accepted coding practices, guidelines, and conventions for ethical, accurate, and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information.
• 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.

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.
• 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 indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major in health information technology/health information management.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series must have either:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation.

Benefits

• Work Schedule: Monday- Friday 7:00am-3:30pm
• Telework: Remote 100% Outside of Area
• Virtual: This is a virtual position.
• Relocation/Recruitment Incentives: Not Authorized
• Permanent Change of Station (PCS): Not Authorized

Grade Determinations

• Medical Records Technician (Coder-Inpatient), GS-8:
• Experience: One year of creditable experience equivalent to the next lower grade level.
• Assignment: Journey level for inpatient MRTs (Coder) to select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems.
• Demonstrated Knowledge, Skills, and Abilities:
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding.
• Ability to accurately perform the full scope of inpatient coding.
• Skill in interpreting and adapting health information guidelines.

Preferred Experience

• 1 year or more of VHA GS-0675-08 MRT Coder- Inpatient experience at a 1a/b VHA facility.
• Experience that is not CDIS or billing experience.

Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service.