Medical Record Technician (Coder-Outpatient and Inpatient)

Description:

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

Requirements:

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 :

• 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. Medical Records Technician Coder (Inpatient & Outpatient) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience & Education:
  • Experience. One year of experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR,
  • Education. See Education Section below. OR,
  • Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. See Education section for appropriate examples of combining education/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. 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 ACDIS.
• Note: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. May 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 :
MRT, GS-8

• Experience. One year of experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities. 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. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
  • Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  • Skill 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.

Preferred Experience: Coding credential from AHIMA or AAPC

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/ .

The full performance level of this vacancy is GS-8.