Medical Records Technician (Coder-Outpatient and Inpatient)

U.S. Department of Veterans Affairs; Tulsa (OK); On-site; USD 45,000 - 65,000; Full time

Job summary

U.S. Department of Veterans Affairs' Eastern Oklahoma VA Healthcare System seeks a Medical Records Technician (Coder) to classify data from patient records in inpatient and outpatient settings.

The role requires knowledge of medical terminology, anatomy/physiology, CPT/ICD coding, and HIM practices. Certification and progression through GS-4 to GS-6 levels are described, with training opportunities in AHIMA/AAPC programs.

Qualifications

• One year of medical terminology, anatomy, physiology, coding, and health record knowledge.
• Associate degree with HIM major or minimum 12 credit hours in HIM.
• AHIMA/AAPC coding program completion leading to certification eligibility.

Responsibilities

• Classify medical data from patient health records in hospital or clinical settings.
• Assign ICD/CPT codes for inpatient and outpatient episodes of care.
• Ensure documentation supports accurate coding and regulatory compliance.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health information technology

Education

Associate degree in health information management

12 credit hours in health information management

AHIMA/AAPC coding program completion

Tools

Electronic health record (EHR) software

Coding/abstracting software

Health information management systems

Job description

This position is located in the Health Information Management (HIM) section at the Eastern Oklahoma VA 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.

Basic Requirements

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.

Certification

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

Grade Determinations

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

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. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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.). 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 inpatient and outpatient episodes of care based on health record documentation. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 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. 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 coding and to 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 HIPAA). Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guideline