Medical Records Technician (Coder-Outpatient)

U.S. Department of Veterans Affairs; Anchorage (AK); On-site; USD 65,000 - 85,000; Full time

Job summary

U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coder) located in Anchorage, AK in the Health Information Management section of the VA Medical Center.

The coder classifies data from patient health records in hospital and related settings, ensuring accurate coding for outpatient and inpatient encounters. The role requires knowledge of medical terminology, anatomy, physiology, and coding systems (ICD-CM, CPT).

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records
• Completion of AHIMA/AAPC coding program or related intense coding training with coursework in anatomy, physiology, medical terminology, basic ICD/diagnostic and CPT coding
• Six months of additional experience with health information management concepts and documentation
• Proficiency in English (spoken and written) as required by VA
• Knowledge of ICD-CM, CPT guidelines and health record documentation standards

Responsibilities

• Code using ICD-CM, CPT, and HCPCS for outpatient and inpatient records
• Abstract and extract data from health records for quality, research, and reimbursement
• Ensure documentation supports coded diagnoses and procedures
• Maintain compliance with confidentiality and privacy regulations
• Interact with clinical staff to resolve coding/documentation issues

Skills

Medical terminology

Anatomy

Physiology

Pathophysiology

Medical coding

Health information management

Education

Associate degree in health information technology/health information management

AHIMA/AAPC coding program

Four-year degree with 24 hours in health information management/technology

Job description

Summary

THIS IS NOT A REMOTE POSITION. THIS POSITION IS PHYSICALLY LOCATED IN ANCHORAGE - AK. This position is located in the Health Information Management (HIM) section at the Anchorage 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.

Qualifications

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 3 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 English Language Proficiency
• MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• 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 Determinations: Medical Records Technician (Coder-Outpatient) - GS-4 Experience or Education
• None beyond basic requirements
• Medical Records Technician (Coder-Outpatient) - GS-5 Experience
• One year of creditable experience equivalent to the next lower grade level
• OR - Education
• Successful completion of four years of education above high school leading to a bachelor'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 management or a related degree with a minimum of 24 semester hours in health information management or technology
• AND Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions (e.g. - the electronic health record - coding and abstracting software - etc.)
• Ability to navigate through and abstract pertinent information from health records
• Knowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines
• Ability to apply knowledge of medical terminology - human anatomy/physiology - and disease processes to accurately assign codes to outpatient/ambulatory surgery records - based on health record documentation
• Knowledge of The Joint Commission requirements - Centers for Medicare and Medicaid Services (CMS) - and/or health record documentation guidelines
• Ability to manage priorities and coordinate work - in order to complete duties within required timeframes - and the ability to follow-up on pending issues
• Medical Records Technician (Coder-Outpatient) - GS-6 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: Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation
• Ability to determine whether health records contain sufficient information for regulatory requirements - are acceptable as legal documents - are adequate for continuity of patient care - and support the assigned codes
• This includes the ability to take appropriate actions if health record contents are not complete - accurate - timely - and/or reliable
• Ability to apply laws and regulations on the confidentiality of health information (e.g. - Privacy Act - Freedom of Information Act - and Health Insurance Portability and Accountability Act (HIPAA))
• Ability to accurately apply the ICD CM - procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting - and CPT guidelines to coding scenarios
• Comprehensive knowledge of current classification systems - such as ICD CM - CPT - and HCPCS - and skill in applying said classifications to outpatient episodes of care - and/or inpatient professional services based on health record documentation
• Medical Records Technician (Coder-Outpatient) - GS-7 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: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record
• Ability to communicate with clinical staff for specific coding and documentation issues - such as recording diagnoses and procedures - ensuring the correct sequencing of diagnoses and/or procedures - and verifying the relationship between health record documentation and coder assignment
• Ability to research and solve coding and documentation related issues
• Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
• Continued under Education

Duties

• Total Rewards of a Allied Health Professional Duties may include - but are not limited to: Completes diagnostic and procedural coded data are necessary for research - epidemiology - outcomes and statistical analysis - financial and strategic planning - reimbursement - evaluation of quality of care - and communication to support the patient's treatment
• Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) - Current Procedural Terminology (CPT) - and/or Healthcare Common Procedure Coding System (HCPCS)
• NOTE: Coders will follow current published ICD-10-CM Official Guidelines for Coding and Reporting - CPT Guidelines - as well as other established industry standard coding guidance such as the American Medical Association (AMA) CPT Assistant and the American Hospital Association's (AHA) Coding Clinic
• Selects and assigns codes from the current version of several coding systems to include ICD - CPT - and/or HCPCS
• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC
• Applies codes based on guidelines specific to certain diagnoses - procedures - and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC
• Performs a comprehensive review of the electronic health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided
• provides technical support in the areas of regulations
• Ensures provider documentation is complete and supports the diagnoses and procedures coded
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data
• Reports incorrect documentation or codes in the electronic patient health record
• Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the electronic health record
• Utilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA databases
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines
• Researches references to resolve any questionable code errors - contacts supervisor as appropriate
• Codes inpatient professional fee services for identified inpatient admissions
• Codes all identified surgical procedures
• Work Schedule: Monday through Friday 8am - 4:30pm Compressed/Flexible: Authorized Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation) Assistance: Not Authorized Pay: Competitive salary and regular salary increases When setting pay - a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade)
• Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual - based on prior [work experience] or military service experience
• Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child
• Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Ad-Hoc only Virtual: This is not a virtual position
• Permanent Change of Station (PCS): Not Authorized