Job Description

BASIC REQUIREMENTS. (a) United States Citizenship: Must be a U. S. citizen. (b) English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English. (c) Certification. MRT (Coder) GS-0675 must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. Certified Coding Associate (CCA) Certified Professional Coder-Apprentice (CPC-A) Certified Outpatient Coding-Apprentice (COC-A) (2) Mastery Level Certification through AHIMA or AAPC. Certified Coding Specialist - Physician-based (CCS-P) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Professional Coder (CPC) Certified Outpatient Coder COC) Certified Inpatient Coder (CIC) Certified Coding Specialist (CCS) (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. Clinical Documentation Improvement Practitioner (CDIP) Certified Clinical Documentation Specialist (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding & the structure/format of a health record. ~OR~ (2) Education. An associate's degree from an accredited college/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 (e.g., courses in medical terminology, anatomy & physiology, medical coding & introduction to health records). ~OR~ (3) Completion of an AHIMA approved coding program /other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, the sponsoring academic institution must be accredited by a national U.S. Department of Education accreditor/comparable international accrediting authority at the time the program was completed (4) Experience/Education Combination. Equivalent combinations of creditable experience/education are qualifying for meeting the basic requirements. (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, and one year above high school, with a minimum of 6 semester hours.. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists/hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical professional supervision. GRADE DETERMINATIONS AND ASSIGNMENTS. (1) Medical records Technician (Coder-Inpatients), GS-4 (a) Experience or Education- None beyond basic requirements above. (2) Medical records Technician (Coder-Inpatients), GS-5 (a) Experience. One year creditable experience equivalent to the next lower grade level ~OR~ (b) Education. Successful completion of a bachelor's degree from accredited college or university. (c) (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs: 1. Ability to use health information technology and various office software products used in MRT (Coder) positions. 2. Ability navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and reporting. 4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation. 5. Knowledge of The Joint Commission requirements CMS and/or health record documentation guidelines. 6. Ability to manage priorities and work to complete duties within the required timeframes and the ability to follow-up on pending issues. (3) Medical records Technician (Coder-Inpatients), GS-6 (a) Experience. One year creditable experience equivalent to the next lower grade level (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HI