Medical Records Technician (Coder-Outpatient and Inpatient)

About the role

This position is located in the Health Information Management (HIM) section at the Hershel Woody Williams VA Medical Center. Medical Records Technician (Coder-Outpatient and Inpatient) 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. Basic Requirements: United States Citizenship. English Language Proficiency. Proficient in spoken and written English. Experience and Education. Experience. 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 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 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 and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience. a.) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and 1 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 6months 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. Candidates 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 ACDIS. Grade Determinations: GS-4: Experience or Education. None beyond basic requirements. GS-5: Experience. 1 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 to the experience above, the candidate must demonstrate all of the following Demonstrated Knowledge, Skills, and Abilities (KSAs): 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 and Reporting, and CPT guidelines; Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and 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 and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6: Experience. 1 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: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation; Ability to determine whether health records contain su

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