MEDICAL RECORDS TECH (CODER)- Auditor Inpatient/Outpatient

Veterans Health Administration; Fayetteville (NC); On-site; USD 55,000 - 70,000; Full time

Job summary

Veterans Health Administration seeks a Medical Records Technician (MRT) coder to classify and abstract health records using ICD-10-CM, CPT, and HCPCS coding systems. The incumbent will assign codes for diagnoses and procedures in inpatient and outpatient settings.

Applicants may be referred pending licensure or certification; full qualifications include appropriate education or certification pathways and eligibility for certification exams through AHIMA or AAPC.

Qualifications

• Experience or education in medical terminology, anatomy, physiology and medical coding.
• Proficiency in health information structures and health records is required.
• Eligibility for coding certification/exam through AHIMA or AAPC.

Skills

Medical terminology

Anatomy

Physiology

Medical coding

Health records

Education

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

AHIMA/AAPC coding program completion

Completion of AHIMA approved coding program

Tools

ICD-10-CM coding

CPT coding

HCPCS coding

Job description

This position is located in the Health Information Management (HIM) section at the Fayetteville VA NC Coastal Health Care System. MRT Auditors are skilled in classifying medical data from inpatient/outpatient health records in the hospital setting, and/or physician-based settings, such as physician offices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis & 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.
• 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 (1) 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, (2) 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; (3) 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; (4) 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. 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).
• GS-09 Grade Determinations: In addition to the Basic Requirements above, candidates must also meet any additional requirements to include KSAs based on grade assignment, GS-9, below. Experience. One year of creditable experience equivalent to the journey grade level, GS-8, of a MRT (Coder). Experience includes: performing all duties of a MRT (Coder) which includes: select and assign codes from current versions of ICD 10 CM, CPT, and HCPCS classification systems to outpatient records, including ambulatory surgeries. Certification. Employees at this level must have a mastery level AHIMA or AAPC certificate. (You must provide this certification as a part of your application package. If you do not provide the proof of certification, your application will be screened out for not meeting this requirement).

Assignments: