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Medical Records Technician (Coder)

Expired Job

Department Of Veterans Affairs Fort Harrison , MT 59636

Posted 4 months ago

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  • Duties

HelpDuties Summary

The Medical Record Technician(Coder) is a position in the Health Information Management Section (HIMS) of the Health Administration Services (HAS) service of the Montana VA Health Care System (MTVAHCS). The duties and responsibilities are carried out throughout the medical center and Community Based Outpatient Clinics (CBOC's) of the medical center. The 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

As a Medical Record Technician (Coder), you are responsible for the following duties to include, but not limited to:

  • Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

  • Selects and assigns codes from the current version of one or more coding systems to include the International Classification of Diseases-Clinical Modification (ICD-9-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding Systems HCPCS.

  • Insures provider documentation is complete and supports the diagnoses and procedures coded.

  • Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.

  • Reports incorrect documentation or codes in the electronic patient record.

  • Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.

  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data.

  • Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in within established timelines.

  • Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

  • Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.

  • Monitors ever-changing regulatory and policy requirements affecting coded information.

  • Complies with coding changes crucial to the accuracy of the facility database as well as all cost recovery programs. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

Work Schedule: The tour of duty for this position is typically Monday-Friday. Virtual work may be authorized for highly qualified applicants.

Financial Disclosure Report: Not required

Travel Required

Occasional travel - You may be expected to travel for this position.

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

  • Designated and/or random drug testing may be required

  • 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. 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).(Transcripts Required).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.(Transcripts Required)

(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.(Transcripts Required)

Must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Grade Determinations:

GS-4 MRT (Coder) - Entry Level

Experience or Education. None beyond basic requirements.

GS-5 MRT (Coder) Developmental Level 1

Experience. One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology.

Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1.Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.);
2.Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and
3.Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues.

GS-6 MRT (Coder) Developmental Level 2

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

Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1.Ability to navigate through health records to find needed information;
2.Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines;
3.Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and
4.Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation.

GS-7 MRT (Coder) Developmental Level 3

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

Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1.Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record;
2.Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment;
3.Ability to research and solve coding and documentation related issues; and
4.Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

GS-8 MRT (Coder) Full Performance Level

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

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 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 PT II, Appendix G-35 dated Sept. 5, 2014. This can be found in the local Human Resources Office.

The full performance level of this vacancy is a GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-5 to GS-8.

Physical Requirements:
Daily intermittent walking, standing, bending, stooping, reaching, and carrying of lightweight items required. Rigid deadlines and need for high degree of accuracy periodically becomes stressful.

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