[Hiring] Medical Records Technician (Coder- Outpatient and Inpatient) @Richard L Roudebush VA Medical Center

Role Description

This position is located in the Health Information Management (HIM) service line. Medical Record Technicians (MRT Coders) 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.
• Performs comprehensive review of documentation within the health record to assign ICD-10-CM and ICD-10-PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, inpatient professional services, and procedures for accurate assignment of DRGs.
• Independently reviews and abstracts clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Codes all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
• Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstracts, assigns, and sequences codes into encoder software to obtain correct 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.
• Queries clinical staff with documentation requirements to support the coding process.
• Enters and corrects information that has been rejected, when necessary.
• Ensures audit findings have been corrected and refiled.
• Uses various computer applications to abstract records, assign codes, and record and transmit data.

Work Schedule

Monday- Friday, 7:00AM-3:30PM EST

Recruitment/Relocation Incentives

• Not Authorized

Permanent Change of Station

• Not Authorized

Pay

Various pay rates, pay will be set according to locality rate of selectee.

Paid Time Off

• 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
• Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

Parental Leave

• After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy

• After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

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 (many federal insurance programs can be carried into retirement).

Remote

This is a remote position where you will work from the location listed above. This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order.

Functional Statement

92946-A

Education Requirements

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.

Qualifications

• Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.
• 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.

Certification

• Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service.

English Language Proficiency

MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Grade Determinations

• In addition to meeting the basic requirements, applicants must meet the below requirements to qualify at the GS 8.
• Experience: 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 and to evaluate the adequacy of the documentation.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity.

Preferred Experience

• 3 years of Inpatient and Outpatient coding experience.

Reference

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

Full Performance Level

The full performance level of this vacancy is GS 8. The actual grade at which an applicant may be selected for this vacancy is GS 8.