This position is located in the Health Information Management section at the Salem VA Medical Center in Salem, VA. The Medical Records Technician (Coder-Inpatient) is skilled in classifying medical data from patient health records. The Medical Records Technician (Coder-Inpatient) analyzes and abstracts patients' health records, and assigns alpha-numeric codes for each diagnosis and procedure.

Duties

Duties include: Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the CVHCS. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD),Procedural Coding System (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program. Codes inpatient professional fee services for identified inpatient admissions. Establishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. 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. Work Schedule: 8:00 AM - 4:30 PM, Monday - Friday Telework: Remote position Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required

Requirements

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 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: 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; ORSuccessful 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). Certification: Apprentice/Associate Level Certification through AHIMA or AAPC, OR Mastery Level Certification through AHIMA or AAPC. English Language Proficiency: Proficient in spoken and written English. 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: In addition to meeting the basic requirements listed above, applicants must meet the grade requirements for Medical Records Technician (Coder-Inpatient). GS-04: Experience or Education. None beyond basic requirements. GS-05: One (1) year of Specialized Experience equivalent to at least the GS-04 grade level and/or 4 years above high school .GS-06: One (1) year of Specialized Experience equivalent to at least the GS-05 grade level. GS-07: One (1) year of Specialized Experience equivalent to at least the GS-06 grade level. GS-08: One year of creditable experience equivalent to GS-07 MRT (Coder-Inpatient) and demonstrate all of the following KSAs: References: VA Handbook 5005, Part II, Appendix G57, Medical Records Technician (Coder) Qualification Standard Preferred experience: 3-5 years of inpatient coding experience with coding certification through AHIMA or AAPC. Physical Requirements: The work involves typing on a computer and coding software requires the use of fingers.

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 Salem VA Medical Center 1970 Roanoke Boulevard Salem, VA 24153 US
• Name: Jessica Krahe
• Phone: (724) 290-8372
• Email: [email protected]