Medical Records Technician (Inpatient Coder) Auditor
Assigns and audits medical codes for documented patient care encounters covering the full range of health care services. Applies advanced knowledge of clinical coding systems, medical terminology, anatomy and physiology, disease process/pathophysiology, treatment modalities, diagnostic tests, pharmacology, procedures, principles and practices of health services. Selects, assigns, and reviews codes from the current version of several clinical classification systems. Adheres to accepted coding practices, guidelines and conventions when selecting the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code(s) to ensure ethical, accurate, and complete medical coding. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program. Monitors ever-changing regulatory and policy requirements affecting coded information. Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record. Uses a variety of Window based applications in day to day activities and duties and competent in use of the health record applications. Audits, assigns, and provides follow up regarding codes for the full spectrum of coding. Reviews coding and assists coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data. Performs audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management. Performs other duties as assigned. Work Schedule:
Monday through Friday 7:
30am to 4:
00pm, NOTE:
This position is authorized for telework however, you MUST be within commuting distance. This is NOT a REMOTE authorized position. Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 10/01/2020. 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. Must be proficient in spoken and written English
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 experience and education are qualifying. The following educational/ training substitutions are appropriate for combining education and
Experience:
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
Mastery Level Certification through AHIMA or AAPC. Current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P),Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Grade Determinations for the GS-9:
MRT (Coder) Auditor (Inpatient) Qualified applicants must demonstrate one year of experience equivalent to the next lower grade MRT (Coder-Inpatient) GS-8 and demonstrate the additional knowledge, skills and abilities at the MRT (Coder) Auditor (Inpatient) GS-9. GS-8 MRT (Coder-Inpatient) Journey Level (a) Experience. 1. One year of creditable experience equivalent to the next lower grade level. (b) Certification. 1. Mastery level certification through AHIMA or AAPC. (c) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient; 2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and inpatient encounters, and/or inpatient professional fee services coding; and 3. 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 and inadequate guidelines. GS-9 MRT (Coder) Auditor (Inpatient) (a) Experience. 1. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Inpatient). (b) Certification. 1. Mastery level certification through AHIMA or AAPC. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (Outpatient, inpatient, outpatient and inpatient combined); 2. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner; 3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements; 4. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy; 5. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. References:
VA Handbook 5005/79, Part II, Appendix G57 MEDICAL RECORD TECHNICIAN Qualification Standard. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-9. Preferred experience-Inpatient/Profee/Surgical Coding experience 3 years or more. Preferred credentials-Certified Coding Specialist, CCS or Certified Coding Specialist, Physician-based, CCS-P Physical Requirements:
Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices.
Estimated Salary: $20 to $28 per hour based on qualifications.
Monday through Friday 7:
30am to 4:
00pm, NOTE:
This position is authorized for telework however, you MUST be within commuting distance. This is NOT a REMOTE authorized position. Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 10/01/2020. 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. Must be proficient in spoken and written English
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 experience and education are qualifying. The following educational/ training substitutions are appropriate for combining education and
Experience:
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either of the following certifications/credentials:
Mastery Level Certification through AHIMA or AAPC. Current mastery level certifications include:
Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P),Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Grade Determinations for the GS-9:
MRT (Coder) Auditor (Inpatient) Qualified applicants must demonstrate one year of experience equivalent to the next lower grade MRT (Coder-Inpatient) GS-8 and demonstrate the additional knowledge, skills and abilities at the MRT (Coder) Auditor (Inpatient) GS-9. GS-8 MRT (Coder-Inpatient) Journey Level (a) Experience. 1. One year of creditable experience equivalent to the next lower grade level. (b) Certification. 1. Mastery level certification through AHIMA or AAPC. (c) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient; 2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and inpatient encounters, and/or inpatient professional fee services coding; and 3. 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 and inadequate guidelines. GS-9 MRT (Coder) Auditor (Inpatient) (a) Experience. 1. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Inpatient). (b) Certification. 1. Mastery level certification through AHIMA or AAPC. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (Outpatient, inpatient, outpatient and inpatient combined); 2. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner; 3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements; 4. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy; 5. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. References:
VA Handbook 5005/79, Part II, Appendix G57 MEDICAL RECORD TECHNICIAN Qualification Standard. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-9. Preferred experience-Inpatient/Profee/Surgical Coding experience 3 years or more. Preferred credentials-Certified Coding Specialist, CCS or Certified Coding Specialist, Physician-based, CCS-P Physical Requirements:
Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices.
- Department:
0675 Medical Records Technician - Salary Range:
$57,508 to $74,762 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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