Truman VA Medical Center is committed to Diversity and Inclusion. Together, we strive to create and maintain a working and learning environment that promotes professional growth and teamwork. We offer an inclusive, equitable, and welcoming environment where we celebrate our individual differences and unite as a team toward a common goal of providing outstanding service to our Nation's Veterans

Duties

100% Telework outside commuting area. The incumbent serves as the Medical Record Technician (Coder-Outpatient) in Health Administration Service Section at Harry S. Truman Veterans Memorial Hospital Healthcare System. The duties of this position include but are not limited to: perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services 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 disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature assign codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC perform a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture insure provider documentation is complete and supports the diagnoses and procedures coded search the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record utilize the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database establish the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement code all Operating Room procedures reported in the Surgical Package of the VistA hospital system review and code assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc Work Schedule: Monday thru Friday; 7:30 am to 4:00 pm Telework: 100% Telework Virtual: This is a virtual position. Functional Statement #: Medical Records Technician - Coder Outpatient FS-000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure/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 December 10, 2019 VA technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management. 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/education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, 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. (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 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. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (GS-4 Entry Level) (2) Mastery Level Certification through AHIMA or AAPC. (3) 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 Determinations: Medical Records Technician, GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician, GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR, Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology. In addition the candidate must demonstrate the Knowledge, Skills, and abilities i. Ability to use health information technology and various office software products used in MRT (Coder) positions ii. Ability to navigate through and abstract pertinent information from health records. iii. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting. iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation. v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. Medical Records Technician, GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. In addition the candidate must demonstrate all of the following KSAs: i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. ii. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. iii. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPM). iv. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. v. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) Medical Records Technician, GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. In addition the candidate must demonstrate all of the following KSAs: i. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record. ii. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, and the correct sequencing of diagnoses and/or procedures iii. Ability to research and solve coding and documentation related issues. iv. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. v. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG. Medical Records Technician, GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. 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. ii. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. iii. 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 inadequate guidelines. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS4 to GS8. Physical Requirements: The work is mostly sedentary. It typically requires sitting with sustained periods of concentration.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Harry S Truman Memorial Veterans Hospital 800 Hospital Drive Columbia, MO 65201 US
• Name: Rachel Gallagher
• Phone: 785-640-9971
• Email: [email protected]