LEAD MEDICAL RECORDS TECHNICIAN (CODER-OUTPATIENT AND INPATIENT)

U.S. Department of Veterans Affairs; Gary (IN); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Remote work

Job summary

U.S. Department of Veterans Affairs is seeking MRTs (Coders) to classify medical data from patient health records in hospital and physician-based settings. The role supports HIM at John J.

Pershing VA Medical Center and requires mastery of coding conventions and documentation standards. Remote work is available with the expectation to reside within 50 miles of a VA Medical Center; schedules include weekday hours and benefits typical of federal employment.

Qualifications

• One year of creditable experience or education meeting basic requirements.
• Eligibility for coding certification/certification exam through AHIMA or AAPC.
• Knowledge of medical terminology and health records structure.

Responsibilities

• Assign codes to documented patient care encounters.
• Abstract data from health records for complete data capture.
• Train others and monitor workload and accuracy.
• Utilize coding software to transmit data to the national VA database.

Skills

Medical terminology

Anatomy

Physiology

Medical coding

Health records

Team collaboration

Documentation review

Education

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

AHIMA/AAPC coding certification eligibility

Coursework in medical terminology, anatomy, physiology

Job description

Summary

This position is located in the Health Information Management (HIM) section at the John J. Pershing 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. These coding practitioners analyze and abstract patients' health records - and assign alpha-numeric codes for each diagnosis and procedure.

This position is located in the Health Information Management (HIM) section at the John J. Pershing 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. These coding practitioners analyze and abstract patients' health records - and assign alpha-numeric codes for each diagnosis and procedure.

Qualifications

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
• 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
• OR 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 - Employees at this level must have a mastery level certification
• Mastery Level Certification through AHIMA or AAPC
• Current mastery level certifications include: Certified Coding Specialist (CCS) - Certified Coding Specialist - Physician-based (CCS-P) - Registered Health Information Technician (RHIT) - Registered Health Information Administrator (RHIA) - Certified Professional Coder (CPC) - Certified Outpatient Coder (COC) - Certified Inpatient Coder (CIC)
• 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)
• GS-9 Grade Determinations: In addition to the basic requirements - certificate requirement - and grade requirements
• the candidates must be able to demonstrate the following knowledge - skills - and abilities: Experience
• One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder) Knowledge - Skills - and Abilities: 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-9. Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service.
  

Duties

• Major duties include - but are not limited to: Assigns codes to documented patient care encounters Monitors ever-changing regulatory and policy requirements affecting coded information Performs a comprehensive review of the patient health records 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 Expertly searches the patient health record to find documentation justifying code assignments Utilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA database Analyzes and recommends improvements in documentation systems Identifies training needs of individuals based on productivity and accuracy reports Monitors the status and progress of work and day-to-day adjustments Required to train others
• Work Schedule: Monday-Friday 8:00am - 4:30pm CST
• 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)
• Functional Statement #: 000000
• Remote: Yes - This position is designated as 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.