Medical Records Technician (Coder-Inpatient)
What you'd do
Announcement will close once 25 applicants is reached This position is located in the Health Information Management (HIM) section at the Sioux Falls VA Medical Center. 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.
Major duties
Temporarily eligible for Remote work within 50 miles of a VA Medical Center. May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review. Total Rewards of a Allied Health Professional Major Duties: Assigns International Classification of Diseases (ICD) and Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes to documented patient care encounters (outpatient and inpatient professional services) covering the full range of health care services provided by the VAMC. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications 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. 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. Abstract, assign, and sequence codes appropriately that support services rendered and conditions documented and for medical necessity. Directly consult/query the clinical staff for clarification of conflicting, incomplete, missing or ambiguous clinical data in the health record. Review and resolve coding edits. Enter and correct information that has been rejected, when necessary. Ensure audit findings have been reviewed, corrected as necessary, apply appropriate comments and refiled. Ensures all documentation is present, accurate, complete and in an appropriate format. Ensures that documentation meets Joint Commission and VA requirements. Identifies problems in documentation and forwards to supervisor as necessary. Reviews documentation regarding conditions that have been adjudicated as a service connection (SC) condition or for special treatment authorities related to exposures or experiences and forwards to Utilization Review as appropriate. Total Rewards of a Allied Health Professional Work Schedule: 8:00 AM - 4:30 PM, Monday- Friday Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs). Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer 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) Telework: Not applicable, this is a remote position. Virtual: This is not a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized
What you need to qualify
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 & 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 Education 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. Dept. 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, and one 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. Certification: 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. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: GS-4 Experience or Education. None beyond basic requirements. GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR Education. Completion of a bachelor's degree from an accredited college or university recognized by the 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. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.). Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation. 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. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)). Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG. GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
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