Medical Records Technician (CDIS-Outpatient and Inpatient)

About the role

This position is in the Health Information Management (HIM) section at the Columbia VA Health Care System. MRTs (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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Reviews the overall quality and completeness of clinical documentation.
• Improves documentation while the patient is still in-house for inpatient cases, and reviews outpatient encounters for clinical staff education.
• Ensures clinical documentation supports proper code selection and reporting of high-quality healthcare data.
• Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.
• Provides education to providers on the need for accurate and complete documentation, appropriate code selection, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Reports incorrect documentation in the electronic patient health record.
• Adheres to accepted coding practices, guidelines, and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or E/M code.
• Maintains awareness of ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.

Requirements

• Must be proficient in written and spoken English.
• Must be able to pass a background/security investigation.

Qualifications

• Basic Requirements:
• 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.
• An associate 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).
• 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.
• 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).
• Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.
• Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates:
• Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient); or an associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); or mastery l