LEAD MEDICAL RECORDS TECHNICIAN (CODER-OUTPATIENT AND INPATIENT)

US-Department-of-Veterans-Affair; Poplar Bluff (MO); Hybrid; USD 65,000 - 90,000; Full time

Job summary

The John J. Pershing VA Medical Center in Missouri seeks a Medical Records Technician (Coder) to classify medical data, assign codes for diagnoses and procedures, and abstract information for hospital and physician-based settings.

Candidates must have required education or certification in health information management and hold a mastery-level AHIMA/AAPC certification. The position is GS-9 and on-site.

Qualifications

• One year of creditable experience showing knowledge of medical terminology and health records.
• Associate's degree with a major in health information technology/management or 12 relevant semester hours.
• Completion of an AHIMA approved coding program leading to coding certification eligibility.
• Mastery level certification such as CCS, RHIA, RHIT, CPC, COC, CIC.

Responsibilities

• Classify medical data from patient health records and assign alpha-numeric codes for diagnoses and procedures.
• Abstract health information and ensure accurate coding for patient care and billing when applicable.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Teamwork & communication

Education

Associate's degree in Health Information Technology

AHIMA approved coding program completion

Job description

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.

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:

• 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.