Med Rec Tech (Med Coder)

Description:

This position is in the Health Information Management Section at the VA Northern California Health Care System. Certified Coders classify medical data from patient health records. Seeking candidates with robust inpatient coding experience for a complex, multi-specialty Acute Care Hospital. Expertise in ICU coding, psychiatric inpatient admissions, complex surgical procedures using ICD10-PCS and DRG assignment is required. Experience in high volume, tertiary, or academic hospitals is preferred.

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.
• Experience: One year of creditable experience that indicates knowledge of medical terminology and general understanding of health records. Six months of the required one year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT (ROI) work. 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, legal aspects of health care, and introduction to health records). OR
• Experience/Education Combination Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements. The following experience and educational/training substitutions are appropriate for combining education and creditable experience:
  • (a) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management courses.
  • (b) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and 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. The training program may be substituted on a month for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures.
• Certification Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

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 Determination :

Medical Records Technician (Coder-Inpatient), GS-08

Experience: One year of creditable experience equivalent to the next lower grade level.

Demonstrated Knowledge, Skills, and Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of the following KSAs:

1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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.
2. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
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 or in adequate guidelines.

Preferred Experience: Minimum of 2 years, full time, inpatient hospital coding experience. Coding for a highly complex, multi-specialty, Acute care hospital which includes coding intensive care unit stays, psychiatric inpatient stays, and inpatient surgical (PCS) coding.

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-08. The actual grade at which an applicant may be selected for this vacancy ranges from GS-04 to GS-08.

Physical Requirements: VA Directive and Handbook 5019, Employee Occupational Health Service.