Medical Records Technician (Coder-Outpatient and Inpatient)

US-Department-of-Veterans-Affair; Orlando (FL); On-site; USD 45,000 - 65,000; Full time

Job summary

Orlando VA Healthcare System is seeking a Medical Records Technician (Coder) in the Health Information Management section. The role focuses on classifying medical data from patient records in inpatient and outpatient hospital settings, with eligibility contingent on meeting certification/licensure requirements.

Candidates may qualify via experience, an associate degree with HIM coursework, AHIMA/AAPC coding program completion, or equivalent combinations, and must meet English language

Qualifications

• Must meet one of the basic requirements: experience, education, or approved coding program.
• Knowledge of medical terminology, anatomy, physiology, and health records is required.
• Certification pathways through AHIMA or AAPC are acceptable for eligibility.

Skills

Medical terminology

Anatomy and physiology

Medical coding

Health records knowledge

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

ICD-CM

PCS

CPT

HCPCS

Job description

This position is located in the Health Information Management (HIM) section of the Business Office at the Orlando VA Healthcare System, Orlando, FL.. MRTs (inpatient/Outpatient 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, multispecialty 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) 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

• (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); (TRANSCRIPTS REQUIRED)

OR

• (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;

OR

• (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

Persons hired or reassigned tto 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.

Grandfathering Provision

All persons employed in VHA as a MRT (Coder) on the effective date of the VA 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. REFER TO THE "ADDITIONAL INFORMATION" SECTION BELOW.

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-Inpatient), GS-4

• (a) Experience or Education. None beyond basic requirements.
• (b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder).

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

• (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR,
• (b) 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.
• (c) Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (d) Demonstrated Knowledge, Skills, and Abilities. REFER TO EDUCATION SECTION BELOW.

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

• (a) Experience. One year of creditable experience equivalent to the next lower grade level.
• (b) Assignment. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (c) Demonstrated Knowledge, Skills, and Abilities. REFER TO EDUCATION SECTION BELOW.

Medical Records Technician (Coder-Inpatient), GS-7

• (a) Experience. One year of creditable experience equivalent to the next lower grade level.
• (b) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (c) Demonstrated Knowledge, Skills, and Abilities. REFER TO EDUCATION SECTION BELOW.

Medical Records Technician (Coder-Inpatient), GS-8 (Full Performance Level)

• (a) Experience. One year of creditable experience equivalent to the next lower grade level.
• (b) Assignment. This is the journey level for this assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• (c) Demonstrated Knowledge, Skills, and Abilities. REFER TO EDUCATION SECTION BELOW.

References:

VA Handbook 5005/122 Part II, Appendix G-57, Medical Record Technician Qualification Standard.

The full performance level (FPL) of this vacancy is GS-08.

Preferred Experience:

3 years coding experience

Physical Requirements

The work is performed in an office setting which adequately lighted, heated and ventilated. The physical demands of the work are generally minor. The work is primarily sedentary (6-8 hrs.) although, there is some walking (1 hr.), bending (1 hr), and carrying of bulky files (1- 10 lbs.) and some extended periods of standing (2 hrs.).