Medical Records Technician - CDIS- Inpatient/Outpatient

U.S. Department of Veterans Affairs; Philadelphia (Philadelphia County); On-site; USD 50,000 - 80,000; Full time

Job summary

An established industry player is seeking a skilled Medical Records Technician (Coder) to join their team. This role involves analyzing and abstracting patient health records while assigning codes for diagnoses and procedures using ICD, CPT, and HCPCS coding systems. The ideal candidate will possess a strong understanding of medical terminology and coding standards, ensuring accuracy and compliance. This position offers a unique opportunity to contribute to the healthcare sector, providing essential support in patient documentation and coding education. If you're passionate about healthcare and coding, this is the perfect role for you.

Qualifications

• One year of experience in medical coding and health records.
• Certification required through AHIMA or AAPC.

Responsibilities

• Analyze and abstract patients' health records.
• Assign alpha-numeric codes for diagnoses and procedures.

Skills

ICD Coding

CPT Coding

HCPCS Coding

Medical Terminology

Anatomy Knowledge

Physiology Knowledge

Data Analysis

Communication Skills

Education

Associate's Degree in Health Information Technology

AHIMA Certification

AAPC Certification

Job description

This job involves analyzing and abstracting patients' health records, assigning alpha-numeric codes for diagnoses and procedures. The role requires expertise in ICD, CPT, and HCPCS coding systems. MRT (Coder) may also provide education on coding and documentation.

Duties

Major duties and responsibilities include, but are not limited to:

Requirements

Qualifications

Basic Requirements:

• United States Citizenship: Non-citizens may only be appointed if qualified citizens cannot be recruited, per VA Policy.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as per 38 U.S.C. § 7403(f).
• Experience and Education:
  • Experience: One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records structure and format.
  • OR, Education: An associate's degree in health information technology/management or related field with at least 12 semester hours in relevant courses.
  • OR, Completion of an AHIMA-approved coding program or similar intensive training program of about one year, leading to certification eligibility.
  • OR, Experience/Education Combination: Equivalent combinations of experience and education, such as six months of relevant experience plus six semester hours of health information courses, or military training covering anatomy, physiology, and health record techniques.
• Certification: Must have certification through AHIMA or AAPC at apprentice/associate, mastery, or clinical documentation improvement levels. Mastery certification is required for higher positions; clinical documentation certification may substitute for mastery in certain roles.
• Loss of Credential: Certifications must be maintained through ongoing education. Failure to do so may result in removal from the occupation or termination.

Current VHA employees may qualify via the Grandfathering Provision if they meet specific criteria.

Grade Determinations

For GS-9 level (Medical Records Technician - CDIS Specialist):

• One year of experience at the MRT (Coder) level, or
• Associate's degree or higher plus three years of clinical documentation improvement experience, or
• Mastery certification plus two years of experience, or
• Clinical experience (e.g., RN, MD, DO) plus one year of clinical documentation improvement experience.

Employees must demonstrate knowledge of coding, anatomy, physiology, pharmacology, data analysis, communication skills, and regulatory standards. Preferred experience includes two years of inpatient and outpatient ICD-10 and CPT coding in an acute care setting.

Additional Information

Refer to VA Qualification Standards for full details. The full performance level is GS-9.

Physical Requirements: Refer to VA Directive and Handbook 5019.

Note: All required documentation must be uploaded before the closing date to verify eligibility. Incomplete applications will be ineligible for referral. Experience must be clearly indicated in your resume.