Medical Records Technician (Coder Inpatient)
What you'd do
This position is located in the Health Information Management (HIM) section at the Minneapolis VA Health Care Systems (ICVAHCS). The Medical Records Technician (Inpatient-Coder) is responsible for the technical duties related to abstracting medical record data and assigning codes using current clinical classifications systems appropriate for the type of care provided.
Major duties
Announcement will close once 50 applicants is reached- 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. Major duties include: 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 consulUquery the clinical staff for clarification of conflicting, incomplete, missing or ambiguous clinical data in the health record. 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. 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. Performs a comprehensive review of the patient health record to abstract medical, ancillary, demographic, social, and administrative data to ensure complete data capture. Work Schedule: 7:00 AM - 1530 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). Telework: Not applicable, this is a remote position. Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized
What you need to qualify
Basic Requirements. U.S. 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. 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, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (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. English Language Proficiency. Must be proficient in spoken & written English. 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: See Education for Grade Requirements. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS4 to GS8. Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of the evaluation or examination.
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