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

Role Description

Inpatient MRTs (Coder) select codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for:

• Diagnosis
• Complications/major complications
• Comorbid/major comorbid conditions
• Surgery and procedures for assignment of diagnosis related groups (DRG)
• Assigning CPT/HCPCS codes

This position is located in the Health Information Management (HIM) section at the Robley Rex VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in various settings. Responsibilities include:

• Analyzing and abstracting patients' health records
• Assigning alpha-numeric codes for each diagnosis and procedure
• Providing education related to coding and documentation
• Independently reviewing and abstracting clinical data
• Consulting with clinical staff for clarification of conflicting data
• Using encoder software for coding
• Ensuring documentation supports assigned codes
• Correcting identified data errors
• Using various computer applications for coding tasks

Qualifications

• United States Citizenship
• Physical Requirements as per VA Directive and Handbook 5019
• Proficiency in spoken and written English
• Certification options:
  • Apprentice/Associate Level Certification through AHIMA or AAPC
  • Mastery Level Certification through AHIMA or AAPC
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS
• Experience or Education:
  • One year of creditable experience in medical terminology, anatomy, physiology, medical coding, and health records
  • Completion of an AHIMA approved coding program or intense coding training program

Requirements

• Medical Records Technician (Coder-Inpatient), GS-4: None beyond basic requirements
• Medical Records Technician (Coder-Inpatient), GS-5:
  • One year of creditable experience equivalent to the next lower grade
  • Successful completion of a bachelor's degree in health information management or related field
• Medical Records Technician (Coder-Inpatient), GS-6:
  • One year of creditable experience equivalent to the next lower grade
• Medical Records Technician (Coder-Inpatient), GS-7:
  • One year of creditable experience equivalent to the next lower grade
• Medical Records Technician (Coder-Inpatient), GS-8:
  • One year of creditable experience equivalent to the next lower grade

Benefits

• Not authorized for relocation/recruitment incentives
• Permanent Change of Station (PCS) not authorized

Company Description

For more information on this qualification standard, please visit VA Qualification Standards .