Lead Medical Records Technician (Coder)

U.S. Department of Veterans Affairs; Loma Linda (CA); On-site; USD 60,000 - 80,000; Full time

Job summary

U.S. Department of Veterans Affairs (VA) - Loma Linda VA Medical Center seeks an MRT (Coder) to classify medical data from patient health records in hospital and physician settings.

The role requires knowledge of medical terminology, anatomy, physiology, and coding practices. Applicants must meet citizenship and English proficiency requirements; education or certification options include an associate degree with HIM coursework or completion of an AHIMA/AAPC approved program.

Qualifications

• Requires knowledge of medical terminology, anatomy, physiology, medical coding, and health records.
• Associates degree with HIM focus or equivalent education accepted.
• Completion of an AHIMA/AAPC approved coding program is acceptable.

Responsibilities

• Classify medical data from patient health records using coding conventions.
• Apply knowledge of coding systems for inpatient and outpatient settings.
• Collaborate with HIM team to ensure accurate record documentation.

Skills

Team leadership

Coding knowledge

Communication

Training skills

Data analysis

Leadership

Education

Associate's degree in health information technology/health information management

AHIMA/AAPC coding program completion

Job description

This position is located in the Health Information Management (HIM) section at the Loma Linda, CA 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. 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.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• 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, 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, 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-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

NOTE

Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification

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

To Qualify for GS 09:

• Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder), GS-08.
• Certification: Employees at this level must have a mastery level certification
• Knowledge, Skills, and Abilities KSAs: Applicants must have ALL of the following KSAs.
  • Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc
  • Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner
  • Ability to effectively communicate, both orally and in writing, in order to meet program objectives
  • Knowledge of training methods and the ability to provide training to new coding staff
  • Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels
  • Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff

Preferred Experience: None

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 09.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.