[Hiring] Medical Records Technician (Coder-Outpatient and Inpatient) @Tennessee Valley HCS - Nashville

Role Description

The Inpatient/Outpatient (Coder) chooses codes from current versions of ICD CM, PCS 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
• Procedures for assignment of diagnosis related groups (DRG)
• Assigning CPT/HCPCS codes

The technician is assigned to the Health Information Management Section, coding/analysis unit, VAMC Memphis, TN. Responsibilities include:

• Selecting and assigning codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems.
• Performing a comprehensive review of documentation within the health record.
• Independently reviewing and abstracting clinical data from the record.
• Coding all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures.
• Consulting with clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data.
• Abstracting, assigning, and sequencing codes into encoder software.
• Reviewing provider health record documentation for consistency with required medical coding nomenclature.
• Querying clinical staff with documentation requirements to support the coding process.
• Entering and correcting information that has been rejected.
• Correcting identified data errors or inconsistencies.
• Ensuring audit findings have been corrected and refiled.
• Using various computer applications to abstract records, assign codes, and record and transmit data.

MRT Coders may be assigned to a single facility or region, such as a consolidated coding unit.

Qualifications

• 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.
• Certification: MRT (Coder) positions in the GS-0675 series in VHA 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.
• Experience and Education:
  • One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
  • 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.
  • Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity.
• Ability to use judgment in completing assignments using incomplete or inadequate guidelines.
• IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
• Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment.

Benefits

• Position is remote work eligible and is exempted from return to office requirements.
• Compressed/Flexible: Negotiable after hire.
• Telework: ADHOC.

Physical Requirements

• The work is primarily sedentary.
• There is walking, bending, and reaching required for filing or locating material.
• Entering data and word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain.