Medical Records Technician (Coder - Inpatient / Outpatient)

US-Department-of-Veterans-Affair; West Palm Beach (FL); On-site; USD 55,000 - 70,000; Full time

Job summary

The Medical Records Technician (Coder - Inpatient / Outpatient) serves in the Health Information Management Service (HIMS) at the West Palm Beach VA Medical Center. Responsibilities include outpatient and inpatient coding to support clinical documentation, workload capture, reimbursement, reporting, and data integrity.

Applicants may be referred prior to meeting all education/certification requirements. Candidates must meet basic citizenship, language, and experience criteria, with AHIMA/AAPC

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records structure.
• Equivalents combining education and experience acceptable per VA standards.
• AHIMA or AAPC coding certification eligibility or certification desirable.

Responsibilities

• Perform outpatient and inpatient coding to support clinical documentation and workload capture.
• Ensure accurate reimbursement, reporting, and healthcare data integrity.
• Analyze health records to identify diagnoses and procedures for coding; evaluate documentation adequacy.

Education

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

AHIMA or AAPC coding program

Healthcare terminology knowledge

Job description

The Medical Records Technician (Coder - Inpatient / Outpatient) serves within the Health Information Management Service (HIMS) at the West Palm Beach VA Medical Center and is responsible for performing outpatient and inpatient coding functions to support accurate clinical documentation, workload capture, reimbursement, reporting, and healthcare data integrity.

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. MSAs must be proficient in spoken and written English in accordance with VA Handbook 5005, Part II, Chapter 3, Section A, paragraph 3.

AND:

Experience and Education-Documentation Submitted

• 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.
• 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);
• 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;
• 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). Please select the proper response for your experience and/or education.

Certification.

• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

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).

GRADE DETERMINATION for MRT (Coder) Inpatient/Outpatient

GS-08

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

AND;

Demonstrated KSAs.

• 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 comments, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• 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.

Physical Requirements:

The work is primarily sedentary with long periods of sitting at a desk, working with computers daily. Some work may require walking in offices and similar areas for meetings. Work may also require walking and standing in conjunction with travel to and attendance at meetings and conferences away from the worksite. The work does not require any special physical effort.