[Hiring] Medical Records Technician (Coder-Outpatient) @Marion VA Medical Center

Role Description

This position is located in the Health Information Management (HIM) in Health Administration Service (HAS) at the Marion, IL VA Medical Center. The Medical Records Technician (Coder Outpatient) is skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based setting, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

• 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, procedures, and health services principles to ensure proper code selection.
• Selects and assigns codes from the current version of several coding systems including ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines, and conventions for ethical, accurate, and complete coding.
• Monitors regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• 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 the patient care provided.
• Expertly searches the patient health record to find documentation justifying code assignment.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
• Uses various computer applications in day-to-day activities, such as Outlook, Excel, Word, and Access.
• Orients and instructs new personnel and/or students on unit operations, coding, abstracting, and use of an electronic health record.
• Works within a team environment; supports peers in meeting goals and deadlines.

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 indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Education: An associate's degree from an accredited college or university in health information technology/management or related degree with a minimum of 12 semester hours in health information technology.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC.
• English Language Proficiency: Must be proficient in spoken and written English.

Requirements

• Experience or Education: None beyond basic requirements for GS-4 level.
• Experience: One year of creditable experience equivalent to the next lower grade level for GS-5 level.
• Demonstrated Knowledge, Skills, and Abilities for GS-5 level:
• Ability to use health information technology and various office software products.
• 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 for accurate code assignment.
• Knowledge of The Joint Commission requirements and health record documentation guidelines.
• Ability to manage priorities and coordinate work to complete duties within required timeframes.
• Experience: One year of creditable experience equivalent to the next lower grade level for GS-6 level.
• Demonstrated Knowledge, Skills, and Abilities for GS-6 level:
• Ability to analyze health records to identify pertinent diagnoses and procedures for coding.
• Ability to determine if health records meet regulatory requirements and are adequate for continuity of patient care.
• Ability to apply laws and regulations on the confidentiality of health information.
• Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
• Comprehensive knowledge of current classification systems and skill in applying classifications to inpatient records.
• Experience: One year of creditable experience equivalent to the next lower grade level for GS-7 level.
• Demonstrated Knowledge, Skills, and Abilities for GS-7 level:
• Skill in applying current coding classifications to various inpatient and outpatient specialty care areas.
• Ability to communicate with clinical staff regarding coding and documentation issues.
• Ability to research and solve coding and documentation related issues.
• Skill in reviewing and correcting system or processing errors.

Benefits

• Work Schedule: Monday - Friday 8:00am - 4:30pm CST
• Telework: Not Eligible
• Virtual: This position is remote work eligible and is currently exempted from return to office requirements.
• Relocation/Recruitment Incentives: Not Authorized
• Permanent Change of Station (PCS): Not authorized