Medical Records Technician (Coder)(Outpatient & Inpatient)

US-Department-of-Veterans-Affair; Kansas City (MO); Hybrid; USD 65,000 - 90,000; Full time

Job summary

The U.S. Department of Veterans Affairs in Kansas City seeks an MRT (Coder) in the Health Information Management (HIM) section at the Kansas City VA Medical Center. You will classify medical data from patient records in hospital and physician settings and support coding for outpatient and inpatient services.

Required qualifications include U.S. citizenship, AHIMA/AAPC coding certification, an associate degree in HIT/HIM or related field, and one year of creditable experience or an AHIMA coding

Qualifications

• Understanding of medical terminology, anatomy, physiology, and disease processes.
• Ability to interpret health records for coding.
• Familiarity with outpatient and inpatient coding concepts.

Skills

Medical terminology knowledge

Anatomy & physiology understanding

Medical coding expertise

Health information management

Education

Associate's degree in HIT/HIM

AHIMA/AAPC coding program

Job description

This position is located in the Health Information Management (HIM) section at the Kansas City 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.

Basic Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens.
• Certification. MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below. NOTE: Certificate submitted must be a current and active certificate.
  • (1) Apprentice/Associate Level Certification through AHIMA or AAPC. OR (2) Mastery Level Certification through AHIMA or AAPC. OR (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • NOTE: You will be disqualified if you do not submit your certificationOR you submit an expired certification.
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records; OR
• Education: An associate's degree from an accredited college or university recognized by the U.S. Dept. of Ed., 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; OR
• AHIMA Coding Program: Completion of an AHIMA approved coding program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. Program must have led to coding certification/certification examination, and accredited by a national U.S. Dept. of Ed. accreditor, or comparable international accrediting authority; OR
• Experience/Education Combination: 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 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 may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

Grade Determinations

• GS-8 Experience Requirement: In addition to the basic requirements, must have 1 year experience equivalent to the next lower level, GS-7.
  • AND
  • Candidates must demonstrate these KSAs:
    1. 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 pathophysiology of the patient.
    2. 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.
    3. Interpreting and adapting health information guidelines that are not 18 completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

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.

Physical Requirements

The work is primarily sedentary.