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

Role Description

This position is located in the Health Information Management (HIM) section at the Dayton 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 position is MRT (Coder-Inpatient).

• Analyze and abstract patients' health records and assign alpha numeric codes for each diagnosis and procedure.
• Independently 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 inpatient settings and specialties.
• Abstract, assign, and sequence codes into encoder software to obtain correct diagnosis related groups (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.
• Enter and correct information that has been rejected, when necessary.
• Ensure audit findings have been corrected and refiled.
• Assign codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA Medical Center.
• Performs a comprehensive review of the patient 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; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Insures provider documentation is complete and supports the diagnoses and procedures coded.
• Reports incorrect documentation or codes in the electronic patient health record.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge.
• Other duties as assigned.

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 creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification or Mastery Level Certification through AHIMA or AAPC.
• Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held.

Benefits

• Work Schedule: Monday - Friday, 8:00 am to 4:30 pm (Eastern Time Zone).
• Pay: Competitive salary and regular salary increases.
• Paid Time Off: 37-50 days of annual paid time off per year.
• Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave.
• Child Care Subsidy: Eligible for a childcare subsidy up to 25% of total eligible childcare costs.
• 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.
• Telework: This position is designated as remote.