Medical Records Technician (Coder-Outpatient and Inpatient)

US-Department-of-Veterans-Affair; New Orleans (LA); On-site; USD 52,000 - 78,000; Full time

Job summary

Southeast Louisiana Veterans Healthcare System seeks a Medical Records Technician (Coder-Outpatient/Inpatient) to classify medical data from patient records, applying ICD-CM, PCS guidelines and CPT codes in both inpatient and outpatient settings.

Roles include navigating health records, abstracting pertinent data, and ensuring accurate coding under Joint Commission and CMS guidelines; positions require basic qualifications and potential grandfathering per VA standards.

Qualifications

• Experience or education showing knowledge of medical terminology and health records.
• Associate degree with HIM/HIT focus and coursework in coding and anatomy/physiology.
• Completion of AHIMA or equivalent coding program leading to certification eligibility.

Skills

Health information tech

Medical terminology

Anatomy and physiology

Medical coding

Health record abstraction

HIPAA knowledge

Prioritization & time management

Office software

EHR navigation

Education

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

12 semester hours in health information management or related courses

AHIMA/AAPC coding program completion

Tools

EHR software

Coding software

Job description

This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System. 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.

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.

Experience and Education.

1. (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.
2. (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);
3. (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;
4. (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.

1. (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
2. (2) Mastery Level Certification through AHIMA or AAPC.
3. (3) 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 Determinations: Medical Records Technician (Coder-Outpatient and Inpatient)

Medical Records Technician, GS-4

Experience or Education. None beyond basic requirements.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-5

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

Education. Successful completion of 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.

Demonstrated Knowledge, Skills, and Abilities.

• i. Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
• ii. Ability to navigate through and abstract pertinent information from health records.
• iii. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
• iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
• v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
• vi. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

Medical Records Technician (Coder-Outpatient and Inpatient), GS-6

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

Demonstrated Knowledge, Skills, and Abilities.

• i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
• ii. 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.
• iii. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
• iv. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
• v. Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
• vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7 and GS-8 Qualification Standards continued in education section.

Preferred Experience:

None.

Reference:

For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is 08. The actual grade at which an applicant may be selected for this vacancy is in the range of 04 to 08.

Physical Requirements:

Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, puling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.

Work Environment:

Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated. However, the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations.