Medical Records Technician (Coder-Outpatient and Inpatient)

About the role

This position is located in the Health Information Management (HIM) section at the Central Alabama Veterans Health Care System (CAVHCS).

Responsibilities

• Applies knowledge of medical record content - medical terminology - anatomy & physiology - diseases processes - and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services.
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) - Current Procedural Terminology (CPT) - and/or Healthcare Common Procedure Coding System (HCPCS).
• With instruction from a senior coder or supervisor learns to select diagnosis - operation - or procedure codes based on the accepted coding practices - guidelines - conventions and policy.
• Sets up the primary and secondary diagnosis and procedure codes for outpatient 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.
• Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations.
• Bundles encounters when appropriate identifies non-billable encounters.
• Applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite.
• Ensures all procedures file to the appropriate Patient Care Encounter (PCE).
• Adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Codes diagnoses from paper forms for VA registries such as Agent Orange - Ionizing Radiation - Persian Gulf - Prisoner of War - etc.
• Works with clinical staff for specific coding and documentation issues.

Requirements

• Basic Requirements: United States Citizenship - English Language Proficiency - 1 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 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~OR~ Completion of an AHIMA approved coding program - or other intense coding training program of approximately 1 year or more that included courses in anatomy and physiology - medical terminology - basic ICD diagnostic/procedural - & basic CPT coding.
• Training program must have led to eligibility for coding certification/certification examination - and sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor - or comparable international accrediting authority at time the program was completed.
• Experience/Education Combination Equivalent combinations of creditable experience & education are qualifying for meeting basic requirements.

Qualifications

• Experience or Education: None beyond basic requirements for GS-4.
• Education: Bachelor's degree from an accredited college or university recognized by 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 for GS-5.
• Experience: 1 year of creditable experience equivalent to next lower grade level or (b) Education - successful completion of 4 years of education above high school leading to a bachelor's degree from an accredited college or university recognized by U.S. Dept 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 for GS-5.

Skills

• Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g. - the electronic health record - coding and abstracting software - etc.).
• Ability to navigate through and abstract pertinent information from health records.
• Knowledge of the ICD CM - PCS Official Conventions and Guidelines for Coding & Reporting - & CPT guidelines.
• Knowledge of medical terminology - human anatomy/physiology - & disease processes to accurately assign codes to inpatient & outpatient episodes of care based on health record documentation.
• Knowledge of The Joint Commission requirements - CMS - and/or health record documentation guidelines.
• Ability to manage priorities & coordinate work to complete duties within required timeframes - & ability to follow-up on pending issues.

Benefits

• Competitive salary and regular salary increases.
• When setting pay - a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA.
• Annual paid time off - 37-50 days per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year).
• Selected applicants may qualify for credit toward annual leave accrual - based on prior [work experience] or military service experience.
• Permanent Change of Station (Relocation Assistance): Not Authorized.
• Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year).
• Selected applicants may qualify for credit toward annual leave accrual - based on prior [work experience] or military service experience.
• Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child.
• Child Care Subsidy: After 60 days of employment.