Medical Records Technician (Coder Outpatient and Inpatient)

US Department of Veterans Affairs; San Diego (CA); Presencial; USD 70.000 - 90.000; Jornada completa

Descripción de la vacante

The US Department of Veterans Affairs is seeking a MRT (Coder) in the Health Information Management (HIM) section at the San Diego VA Medical Center. The coder will classify medical data from patient health records in hospital and physician settings, assigning alpha-numeric codes for diagnoses and procedures.

Experience in medical terminology, anatomy, physiology, and coding is required; eligibility for AHIMA/AAPC certification is expected.

Formación

• 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, medical coding, and the structure and format of a health records.
• An associate's degree from an accredited college or university with major in health information technology/health information management, or related degree with 12 semester hours in health information technology/health information management.
• Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year that led to eligibility for coding certification/examination.
• Equivalent combinations of creditable experience and education are qualifying, with substitutions such as six months of experience with 6 semester hours of health information technology courses, or military training with further experience.

Conocimientos

Medical terminology

Anatomy

Physiology

Medical coding

Health records

English proficiency

Educación

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

AHIMA or AAPC coding certification program

AHIMA approved coding program completion

Descripción del empleo

This position is located in the Health Information Management (HIM) section at the San Diego 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.



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. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• 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); 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 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.

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: GS-8 Medical Records Technician (Coder-Outpatient-Inpatient)

Experience: One year of creditable experience equivalent to the next lower grade level, GS-7.

Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs:

i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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.
ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
iii. 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.

References: December 10, 2019 VA Handbook 5005/122, PART II, APPENDIX G57.The full performance level of this vacancy is GS-8.

Physical Requirements: Duties require extensive use of fingers to perform keyboarding and the ability to hear request by phone and in person. This is a primarily sedentary position, but the work requires some walking, bending, stooping, and carrying of light objects such as manuals, documents, and etc. Concentration and sustained performance under prolonged stress is required because of the time factors involved in completion of work assignments within deadlines.