[Hiring] Medical Records Technician (Coder-Outpatient and Inpatient) @New Orleans VA Medical Center

Role Description

This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System. 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.

• Analyze and abstract patients' health records, assigning alpha-numeric codes for each diagnosis and procedure.
• Possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).
• Provide education related to coding and documentation.
• Assign codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
• Have basic knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
• Select and assign codes from the current version of one or more coding systems.
• Adhere to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding.
• Monitor regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Perform a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data.
• Assist facility staff with documentation requirements to accurately reflect the patient care provided.
• Consult with professional staff for clarification of conflicting or ambiguous clinical data.
• Search the patient health record to find documentation justifying code assignment.
• Utilize the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
• Use a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access.

Qualifications

• Medical Records Technician (Coder-Outpatient and Inpatient), GS-7
• One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities:
  • Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas.
  • Ability to communicate with clinical staff for specific coding and documentation issues.
  • Ability to research and solve coding and documentation related issues.
  • Skill in reviewing and correcting system or processing errors.
  • Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators.
• Medical Records Technician (Coder-Outpatient and Inpatient), GS-8
• One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities:
  • Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding.
  • Ability to accurately perform the full scope of outpatient coding and inpatient facility coding.
  • Skill in interpreting and adapting health information guidelines.

Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens.
• 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 with a major field of study in health information technology/health information management, or related degree.
• Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC.

Benefits

• Competitive salary and regular salary increases.
• 37-50 days of annual paid time off per year.
• Up to 12 weeks of paid parental leave after 12 months of employment.
• Childcare subsidy for eligible employees after 60 days of employment.
• Traditional federal pension and federal 401K with up to 5% contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance.
• Remote position with potential return to office requirements.