Medical Record Technician (Coder- Inpatient and Outpatient)
This position is located in the Health Information Management (HIM) section at the Ralph H. Johnson VA Medical Center. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Accurately assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Provides daily productivity reports via electronic mail, reporting all workload completed. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Position located at the Montague Avenue Annex in North Charleston. Virtual:
Available for highly qualified candidates with VA Coding experience Work Schedule:
7:
30 am - 4:
00 pm, Monday - Friday 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. 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. Experience and Education:
Experience. One year 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 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 and physiology, medical coding, and introduction to health records); OR, 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. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable
Experience:
Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, an done year above high school, with a minimum of 6 semester hours of health information technology courses. Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six 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-0675series in VHA must have either (1), or (2) below:
(1)Apprentice/Associate Level Certification through AHIMA or AAPC. (2)Mastery Level Certification through AHIMA or AAPC. Physical Requirements:
May include but not limited to standing up to two hours per day, use of both hands, use of fingers, and sitting up to eight hours per day. English Language Proficiency:
MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply 1. Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation. 2. Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. 3. MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. 4. MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation. 5. Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. Grade Determinations:
Medical Records Technician (Coder-Outpatient and Inpatient), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Outpatient and Inpatient), GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR, Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology. Medical Records Technician (Coder-Outpatient and Inpatient), GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. Medical Records Technician (Coder-Outpatient and Inpatient), GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. Medical Records Technician (Coder-Outpatient and Inpatient), GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. References:
VA Handbook 5005/122, PART II APPENDIX G57, MEDICAL RECORDS TECHNICIAN (CODER) QUALIFICATION STANDARDS, December 10, 2019. The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.
Estimated Salary: $20 to $28 per hour based on qualifications.
Available for highly qualified candidates with VA Coding experience Work Schedule:
7:
30 am - 4:
00 pm, Monday - Friday 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. 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. Experience and Education:
Experience. One year 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 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 and physiology, medical coding, and introduction to health records); OR, 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. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable
Experience:
Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, an done year above high school, with a minimum of 6 semester hours of health information technology courses. Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six 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-0675series in VHA must have either (1), or (2) below:
(1)Apprentice/Associate Level Certification through AHIMA or AAPC. (2)Mastery Level Certification through AHIMA or AAPC. Physical Requirements:
May include but not limited to standing up to two hours per day, use of both hands, use of fingers, and sitting up to eight hours per day. English Language Proficiency:
MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply 1. Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation. 2. Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. 3. MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. 4. MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation. 5. Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. Grade Determinations:
Medical Records Technician (Coder-Outpatient and Inpatient), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Outpatient and Inpatient), GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR, Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology. Medical Records Technician (Coder-Outpatient and Inpatient), GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. Medical Records Technician (Coder-Outpatient and Inpatient), GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. Medical Records Technician (Coder-Outpatient and Inpatient), GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. References:
VA Handbook 5005/122, PART II APPENDIX G57, MEDICAL RECORDS TECHNICIAN (CODER) QUALIFICATION STANDARDS, December 10, 2019. The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.
- Department:
0675 Medical Records Technician - Salary Range:
$31,208 to $62,269 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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