Lead Medical Records Technician (Coder)

Summary This position is in the Health Information Management (HIM) section at the Lt. Col. Luke Weathers - Jr. VA Medical Center. Medical Records Technicians (MRT) (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics - and specialty centers. 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 English Language Proficiency - MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f)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 recordsOR - 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 codingThe 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 completedOR - Experience/Education Combination - Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsThe following educational/training substitutions are appropriate for combining education and creditable experience: (a) 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(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 health record techniques and proceduresAlso - 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(2) Mastery Level Certification through AHIMA or AAPC(3) Clinical Documentation Improvement Certification through AHIMA or ACDISNOTE: Mastery level certification is required for all positions above the journey levelhowever - for clinical documentation improvement specialist assignments - a clinical documentation improvement certification may be substituted for a mastery level certificationMay 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: GS-9 Lead Medical Records Technician (Coder) Experience: One year of creditable experience equivalent to the journey grade level MRT (Coder)Certification: Employees at this level must have a mastery level certificationDemonstrated 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 - etcAdvanced 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 mannerAbility to effectively communicate - both orally and in writing - in order to meet program objectivesKnowledge of training methods and the ability to provide training to new coding staffAbility to collect and analyze data and present results in various formats - which may include presenting reports to various organizational levelsLeadership skills - including interpersonal relations and conflict resolution between employees - managers - and clinical staffReference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/This vacancy is above the full performance level at the GS-9. Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service. Duties These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedureTo perform this task - they must possess expertise in International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and the Healthcare Common Procedure Coding System (HCPCS)MRT (Coder) may also provide education related to coding and documentationFor all assignments above the journey level - the higher-level duties must consist of significant scope - complexity (difficulty) - range of variety - and be performed by the incumbent at least 25% of the timeLead MRTs (Coder) must be able to perform all duties of a MRT (Coder)Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracyprovide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulationsinitiate - prepare - and maintain various reports - and analyze dataand may also coordinate - assign - and monitor workflowThey provide input for performance evaluations and hiringDuties include but are not limited to the following: Complete and accurate diagnostic and procedural coded data are necessary for research - epidemiology - outcomes and statistical analysis - financial and strategic planning - reimbursement - evaluation of quality of care - and communication to support the patient's treatmentDiagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) - Current Procedural Terminology (CPT) - and/or Healthcare Common Procedure Coding System (HCPCS)Adheres to accepted coding practices - guidelines and conventions when choosing the most appropriate diagnosis - operation - procedure - ancillary - or evaluation and management (E/M) code to ensure ethical - accurate - and complete codingMonitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMCPerforms a comprehensive review of the electronic health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data captureAssists facility staff with documentation requirements to completely and accurately reflect the patient care providedprovides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencingExpertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient recordOrients and instructs new personnel and/or students from affiliated health information or medical record technology programs - at the direction of the supervisor - on unit operations - coding - abstracting - and use of an electronic health recordGives on the job training to new coders and students to provide the individual with the basic knowledge - skill - and ability to perform the full range of routine and non-routine responsibilities requiredTrains and works closely with professional and administrative staff to assist in the development - maintenance and usage of ICD and CPT codes to ensure accurate data captureReviews - audits - trains - monitors - and completes special assignments within specified time framesWork Schedule: Monday - Friday7:30 am - 4:00 pm Telework: Not AvailableRemote: This position currently has a mid-term Return to Office (RTO) extension of 180 daysPlease note that this extension is subject to changeCandidates may be required to return to the office if agency policy is updated or if the exemption is not extendedMust be able to travel within 50 miles of a VA Facility if remote status is cancelledVirtual: This is not a virtual positionFunctional Statement #: 000000 Relocation/Recruitment Incentives: Not AuthorizedPermanent Change of Station (PCS): Not Authorized.