Medical Records Technician (Coder-Inpatient)
What you'd do
This position is in the Health Information Management (HIM) section at the Joseph Maxwell Cleland Atlanta 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. THIS IS A REMOTE POSITION
Major duties
Total Rewards of a Allied Health Professional Duties include however, are not limited to: Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC. Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases. Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program. Codes all identified surgical procedures; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; adds Anesthesia and Pathology codes for all billable surgical cases, which may involve creating the encounters. Establishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters following applicable regulations, instructions, and requirements for allowable reimbursement. Uses a variety of computer applications in day-to-day activities and duties, such as Microsoft Outlook, Excel, Word, and Teams; competent in use of electronic health record applications as well as the encoder product suite. Work Schedule: Monday-Friday 7:30am - 4:00pm. Work Schedule is subject to change based on agency need. Recruitment Incentive (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 Available Virtual: This is not a virtual position. Functional Statement #: 62214F 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. English Language Proficiency: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). Experience and Education: Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR, Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, 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 experience and education are qualifying. (a) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year 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 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. 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. 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: Medical Records Technician (Coder-Inpatient), GS-8: (a) Experience. One year of creditable experience equivalent to the next lower grade level. (b) Assignment. This is the journey level for this assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/ or assigning CPT/HCPCS codes for inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They must abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They also enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit AND( c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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 comments, and the disease process/pathophysiology of the patient. ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. iii. 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. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-08. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Services.
Before you apply
Federal applications are different: your resume should be 3–5 pages and mirror the language of this announcement. Read our federal resume guide first — it's the #1 reason qualified people get screened out.
Don't miss the next one.
Get an email the moment a similar federal job opens — postings can close in as little as 5 days.