Medical Records Technician (Coder Outpatient/Inpatient)

Description:

This position is located in the Health Information Management section at Long Beach VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alphanumeric codes for each diagnosis and procedure.

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Requirements:

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.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience: At least one (1) 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 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

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).

• Completion of an AHIMA approved Coding Program: Completed 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 education/training substitutions are appropriate for combining education and creditable experience:
  • 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.
• Successful completion of a course of 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 MRT Coder.
• Certification Requirement: Mastery Level Certification through AHIMA or AAPC or Clinical Documentation Improvement Certification through AHIMA or ACDIS. ( Required for this position )
• Master Level Certification : Certification is limited to those obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Informatic Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).

Clinical Documentation Improvement Certification . This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.

NOTE: Copy of Certifications will be required at time of application.

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 for GS-08 :

Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);
OR, An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
OR, Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

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 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 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.
iii. Skill in interpreting and adapting health information guidelines that are not 19 completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Please refer to the Additional Information section for Grade Determination information at the GS-04, 05, 06 and 07 grade levels.

References: References: VA Handbook, 5005, Part II, Appendix G57

The full performance level of this vacancy is GS-08.

Physical Requirements: This position is primarily sedentary.