MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification of Diseases, Current Procedural Terminology, and the Healthcare Common Procedure Coding System.

Duties

Medical Records Technician (Coder) Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding. MRT (Coder) Auditors act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports. They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data. Auditors perform audits of encounters to identify areas of non-compliance in coding and facilitate improved overall quality, completeness, and accuracy of coded data. They provide recommendations on appropriate coding and assist facility staff with documentation requirements to completely and accurately reflect the patient care provided. They provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. They maintain statistical database(s) to track the results and validate the program. Duties include, but are not limited to:

Requirements

Qualifications

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 and Education: 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 creditable experience and education are qualifying for meeting the basic requirements. The following educational/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 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 health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). AND the following: Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have Mastery Level Certification through AHIMA or AAPC. Mastery Level Certification-acceptable 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). English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). 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: Medical Records Technician (Coder) Auditor, GS-9 Experience: One year of creditable experience equivalent to the next lower grade level GS-8 level. Examples of experience at the MRT (Coder) Auditor GS-8 level are: select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and/or outpatient records; independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties; directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record; abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered; review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature; query clinical staff with documentation requirements to support the coding process; enter and correct information that has been rejected, when necessary; correct any identified data errors or inconsistencies; ensure audit findings have been corrected and refiled; and use various computer applications to abstract records, assign codes, and record and transmit data. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. Knowledge of training methods and the ability to provide training to new coding staff. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. References: VA Handbook 5005/122, Part II, Appendix G57, Medical Records Technician (Coder) Qualification Standard Physical Requirements: See VA Directive and Handbook 5019. The position involves work that is mainly sedentary but requires some bending, walking, standing and lifting/carrying (under 15lb) of supplies, patient records, staff and patient mail. Some assignments may involve more frequent walking, but these assignments may involve more frequent walking, but these assignments require no unusual physical demands to perform work. The incumbent will need to have the ability to verbally communicate and hear (aid permitted) using a telephone and must be able to type and operate computer equipment as an essential part of their position. The incumbent must be able to work closely with internal and external customers in a face to face setting. Work Environment: Work is performed primarily in a patient care setting; adequately lighted, temperature controlled, and ventilated. Office temperatures fluctuate periodically; involves everyday risks or discomforts which require normal safety precautions typical of such places as clinics, offices, meeting and training rooms or libraries; exposure to noise and dust on occasion. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures.

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.

Contacts

• Address Huntington VA Medical Center 1540 Spring Valley Drive Huntington, WV 25704 US
• Name: Samantha Robaina
• Phone: 410-605-7000
• Email: [email protected]