Medical Records Technician (Coder- Outpatient and Inpatient)

US-Department-of-Veterans-Affair; United States; Remote; USD 55,000 - 75,000; Full time

Job summary

The Department of Veterans Affairs seeks a Medical Record Technician (MRT Coder) to classify and abstract health records, assign ICD/CPT codes, and support coding accuracy in hospital or physician office settings. Responsibilities include analyzing records, ensuring documentation supports codes, and maintaining confidentiality.

Applicants must meet VA education, certification, and experience requirements and may be considered for positions GS-0675 coding series; Mastery or AHIMA/AAPC credentials

Qualifications

• One year of creditable experience in medical terminology, anatomy, physiology, coding, and health records.
• Associate degree or coding program with relevant health information focus.
• Certification through AHIMA or AAPC or substitution aligned with VA standards.

Responsibilities

• Analyze health records to identify diagnoses and procedures for coding.
• Abstract health information and assign accurate ICD/ CPT codes.
• Ensure documentation supports coding and maintain data quality.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health records

Education

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

AHIMA/AAPC coding program

Job description

This position is located in the Health Information Management (HIM) service line. Medical Record Technicians (MRT Coders) 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. 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:
  • 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:
    • (a) Six months of creditable experience that indicates knowledge of medical 4 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

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service.

English Language Proficiency

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

Grade Determinations

• 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. 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.
  • Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  • 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.

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).

Preferred Experience

3 years of Inpatient and Outpatient coding experience.

Reference

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

The full performance level of this vacancy is GS 8. The actual grade at which an applicant may be selected for this vacancy is GS 8.