Lead Medical Records Technician (Coder)

US-Department-of-Veterans-Affair; Pineville (LA); On-site; USD 54,000 - 75,000; Full time

Job summary

US Department of Veterans Affairs is seeking a Medical Records Technician (Coder) to classify medical data from patient health records in the hospital setting or physician-based settings, ensuring accurate coding and timely documentation. The role requires one year of creditable experience or alternative eligible education, with opportunities for AHIMA/AAPC certifications.

The incumbent will work within the Health Information Management (HIM) section at the Central Alexandria VA Health Care

Qualifications

• One year of creditable experience showing knowledge of medical terminology, anatomy/physiology, medical coding, and health records structure.
• Education alternatives include an associate degree with health information management coursework orAHIMA/AAPC approved coding programs.
• Certification options include AHIMA or AAPC apprentice/associate, mastery, and clinical documentation improvement certifications.

Responsibilities

• Classify medical data from patient health records in hospital or physician-based settings.
• Apply current coding classification systems to inpatient and outpatient records.
• Collaborate with clinical staff to ensure accurate documentation and coding.
• Provide guidance and training to new coding staff as needed.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health records

English proficiency

Education

Associate's degree in health information management

Tools

ICD-10-CM/PCS

CPT coding

Job description

This position is located in the Health Information Management (HIM) section at the Central Alexandria VA Health Care System. Medical Records Technician (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:
• (a) 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.
• (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 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:

• (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.

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:

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: (KSAs must be clearly reflected in resume under description of duties in order to be found qualified for this position/grade level).

Lead Medical Records Technician (Coder), GS-9:

Experience: One year of creditable experience equivalent to the journey grade level MRT (Coder)

Certification:

Employees at this level must have a mastery level certification

Demonstrated Knowledge, Skills, and Abilities:

In addition to the experience above, the candidate must demonstrate 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.

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:

Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, puling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.

Work Environment:

Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated. However, the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations.