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Medical Records Technician (Coder)

Expired Job

Department Of Veterans Affairs Manchester , NH 03101

Posted 5 months ago

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  • Duties

HelpDuties Summary

This position is located in the Health Information Management Section (HIMS) in Business Office Service Line in Manchester, NH. The Medical Records Technician (Coder) is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided.

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Responsibilities

The Medical Records Technician (Coder) is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided. Major duties and functions include but are not limited to:

  • Navigate through health records to find needed information to assign codes to encounters (inpatient or outpatient) for the specialty and subspecialty health care services

  • Select and assign codes from the current version of one of more coding system (ICD---CM, CPT, HCPCS)

  • Apply laws and regulations on the confidentiality of health information

  • Ensure that the provider documentation is complete and support the correct sequencing of diagnosis and procedures coded

  • Analyze the medical record to identify all pertinent diagnosis and procedure for coding and to evaluate the adequacy of the documentation

  • Conduct re-review of ICD-10 codes to determine if based on the documentation the specific VERA coding requirements were followed

  • Review and code inpatient professional fee services for identified inpatient admissions for Non-VA Care

  • Establish the primary and secondary diagnosis and procedure codes for billable outpatient encounters

  • Code all surgery procedures in the surgical package in QuadraMed, ensure all procedures file to the appropriate Patient Care Encounter (PCE), and add Anesthesia and Pathology codes ot the PCE encounter

  • Update codes for current inpatient and Contact Nursing Home admissions

  • Perform other related duties as assigned

Work Schedule: Full-Time, Monday

  • Friday. Day Shift

Financial Disclosure Report: Not required

Travel Required

Not required

Supervisory status

No

Promotion Potential
8

  • Job family (Series)
    0675 Medical Records Technician

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  • Requirements

HelpRequirements Conditions of Employment

  • You must be a U.S. Citizen to apply for this job

  • Selective Service Registration is required for males born after 12/31/1959

  • You may be required to serve a probationary period

  • Subject to a background/security investigation

  • Must be proficient in written and spoken English

  • Selected applicants will be required to complete an online onboarding process

Qualifications

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 experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.

OR,

  • Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).

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.

Grandfathering Provision. All persons employed in VHA as a MRT on the effective date of this qualification standard (September 5, 2014) are considered to have met all qualification requirements for the title, series and grade held, including positive education that is part of the basic requirements of the occupation.

English Language Proficiency: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Grade Determinations: In addition to the basic requirements of employment, you must meet the following criteria to be qualified at GS-08 Medical Records Technician (MRT) (Coder) position. NOTE: Creditable Experience

  • To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current health information or health record technology and/or cancer registry practice and may be paid or non-paid employment. (e.g., analyzing and abstracting medical record data; assign codes using clinical classification system; and providing education related to coding and documentation). Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be equivalent to the next lower grade level. Experience satisfying this requirement must be active practice, which is paid/non-paid employment as a MRT in the parenthetical title. Part-time experience as a professional MRT is creditable according to its relationship to the full-time workweek. For example, a MRT would receive 1 week of full-time credit for each 2 weeks of half-time work.

GS-08 MRT (Coder)

  • Full Performance Level: Experience. One year of experience equivalent to the next lower grade level (GS-07). Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 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 comments, 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 outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and 3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

References: VA Handbook 5005/79 Part II Appendix G35. Medical Record Technician Qualification Standard GS-675

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

Physical Requirements:
The work is primarily in a sedentary manner. However, there will be some walking, bending, reaching, stopping, lifting, carrying, and pushing of medical records or books. There will be extensive physical demand of constant typing on a keyboard on a PC.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.


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Medical Records Technician (Coder)

Expired Job

Department Of Veterans Affairs