Medical Records Technician (Coder-Outpatient and Inpatient)

Job Description

Basic Requirements: 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: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience or Education: 1year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. ~OR~ Education. An associate's degree from an accredited college or university recognized by 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; ~OR~ Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. Training program must have led to eligibility for coding certification/certification examination, and sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at time the program was completed;~OR~ Experience/Education Combination. Equivalent combinations of creditable experience & education are qualifying for meeting basic requirements. Following educational/training substitutions are appropriate for combining education and creditable experience:(a) 6months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and health record, and 1year above high school, with a minimum of 6 semester hours of health information technology courses.(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by Armed Forces or U.S. Maritime Service, under close medical & professional supervision, may be substituted on a month-for-month basis for up to 6months of experience provided training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:(1) Apprentice/Associate Level Certification through AHIMA or AAPC.(2) Mastery Level Certification through AHIMA or AAPC.(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determinations :MRT (Coder-Outpatient and Inpatient): GS-4 Experience or Education. None beyond basic requirements. GS-5 1year of creditable experience equivalent to next lower grade level; OR, (b) Education. Successful completion of 4years of education above high school leading to a bachelor's degree from an accredited college or university recognized by U.S. Dept of Education, with a major field of study in health information management or a related degree with a minimum of 24 semester hours in health information management or technology. KSAs In addition to experience above, and demonstrate all of the following KSAs: i. Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.). ii. Ability to navigate through and abstract pertinent information from health records. iii. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, & CPT guidelines. iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient & outpatient episodes of care based on health record documentation. v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. vi. Ability to manage priorities & coordinate work to complete duties within required timeframes, & ability to follow-up on pending issues. GS-6 1year of creditable experience equivalent to next lower grade level. KSAs In addition to experience above, must demonstrate all of following KSAs: i. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding and to evaluate adequacy of documentation. ii. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, & support assigned codes. This includes ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. iii. Ability to apply laws and regulations on confidentiality of health information (e.g., Privacy A