Medical Records Tech (Coder-Outpatient)

US-Department-of-Veterans-Affair; Dayton (OH); Remote; USD 58,000 - 70,000; Full time

Job summary

Dayton Ohio Veterans Affairs Medical Center is seeking a Medical Records Technician (Coder-Outpatient) responsible for performing the full scope of outpatient coding within the Health Information Management section. The role requires knowledge of medical terminology, anatomy, physiology, and coding with an emphasis on accurate documentation and record evaluation.

The position emphasizes professional certification and continuing education, with options for education/experience substitutions.

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, medical coding, and the health record structure.
• Associate degree with health information technology/health information management coursework (or related degree with 12+ semester hours in HIT/HIM).
• Completion of AHIMA approved coding program or equivalent training leading to coding certification eligibility.
• Experience/education combination acceptable with substitutions as described in the standard.

Responsibilities

• Perform the full scope of outpatient coding for the medical center.
• Analyze health records to identify diagnoses and procedures for coding and verify documentation.
• Apply coding guidelines and use judgment to handle gaps or ambiguities in guidelines.
• Maintain qualifications and certifications as required by VA.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health records

Education

Associate degree in health information technology/health information management

AHIMA/AAPC coding certification program

Job description

The Dayton Ohio Veterans Affairs Medical Center is recruiting for a well-qualified Medical Records Technician (Coder- Outpatient) within the Health Information Management section. This position will perform the full scope of outpatient coding. Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder).

Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means.

Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time work week. For example, an MRT would receive one week of full-time credit for each two weeks of half-time work.

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 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.

Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.

Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:

(1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

(2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.

(3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.

(4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

(5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Grade Determinations

Medical Records Technician (Coder-Outpatient), GS-8

Experience. One year of creditable experience equivalent to the next lower grade level.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient.

ii. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.

iii. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

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-8. The actual grade at which an applicant may be selected for this vacancy is GS-8.