Medical Records Technician (Coder-Inpatient)

Summary

This position is located in the Health Information Management (HIM) section at the Phoenix VA Medical Center. 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.

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English
• Certifications: MRT (Coder) GS-0675 must have either (1) - (2) - or (3) below:
• (1) Apprentice/Associate Level Certification through AHIMA or AAPCC
• (2) Mastery Level Certification through AHIMA or AAPCC
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDI
• Preferred Experience: 1 year as a Certified MRT (Coder-Inpatient) Grade Determinations: Medical Records Technician (Coder-Inpatients) - GS-8 (a) Experience
• Demonstrated Knowledge - Skills - and Abilities (KSAs): In addition to the experience - the candidate must demonstrate all of the following KSAs:
• 1Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation
• 2Ability to accurately perform the full scope of inpatient coding - including inpatient discharges - surgical cases - diagnostic studies and procedures - and inpatient professional services
• 3Skill 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

Physical Requirements

The work is primarily sedentaryThere is walking - bending & reaching required - such as for filing or locating material & carrying items such as reports - documents/supplies.

Duties

30 Day Hiring Model The Department of Veterans Affairs is implementing a streamlined 30-Day Hiring Model designed to accelerate hiring while maintaining the highest standards of merit-based selectionThis improved process reduces traditional hiring timelines by integrating early coordination - faster assessments - and efficient pre-employment actionsApplicants can expect a more transparent - predictable - and efficient hiring journey from announcement to entry on dutyWhat Applicants Can Expect Expedited Candidate Review Once the announcement closes - Human Resources will quickly review applications - issue certificates of eligible candidates the day after the announcement closes and refer applicants for hiring manager considerationQuick Interviews & References HR may arrange interviews and will request references within 3-5 days after being referred to the hiring managerStreamlined Pre-Employment Requirements: Following a tentative offer - applicants should be prepared to complete required steps - such as fingerprinting and background check - credentialing - and medical examination within 3 days of the offerClear and Timely Communication: Applicants will receive clear communication at key milestones - including referral - tentative offer - and onboarding instructionsAfter meeting pre-employment requirements - candidates will receive a final job offer and start dateOnboarding tasks may continue after starting - with HR ensuring timely completion for a smooth transition into VA serviceIf selected - applicants should be prepared to come on board within 30 days of the announcement closingSelects and assigns codes from the current version of several coding systems to include ICD - CPT - and/or HCPCSAssigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMCPatient encounters are often complicated and complex requiring extensive coding expertiseApplies advanced knowledge of medical terminology - anatomy & physiology - disease processes - treatment modalities - diagnostic tests - medications - procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selectionAdheres 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 codingApplies codes based on guidelines specific to certain diagnoses - procedures - and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needsPerforms a comprehensive review of the electronic health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data captureWork Schedule: Full-Time - Monday - Friday - 7am - 3:30pm Virtual: This is a virtual positionFunctional Statement #: 00000 Relocation/Recruitment Incentives: Not Authorized