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Medical Records Technician-Coder Outpatient-Inpatient REMOTE

Employer
USAJobs
Location
Wallops Island, Virginia
Closing date
Feb 11, 2023
Duties

**This is an OPEN CONTINUOUS ANNOUNCEMENT and will remain open until 4/10/2023. The initial cut-off date for referral of eligible applications will be January 24, 2023. Eligible applications received after that date will be referred at regular intervals or as additional vacancies occur on an as-needed basis until positions are filled.**

Duties
  • Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services,
  • Patient encounters are often complicated and complex requiring extensive coding expertise.
  • Applies 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,
  • Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD),
  • Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
  • Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation
  • Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings)
  • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
  • Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
  • Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
  • Patient health records may be paper or electronic.
  • Report to accrediting and peer review organizations, to bill insurance companies and other agencies.
  • Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
  • Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
  • Insures provider documentation is complete and supports the diagnoses and procedures coded.
  • Directly consults with the professional staff for clarification of conflicting data.
  • Reports incorrect documentation or codes in the electronic patient health record.
  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
  • Corrects any identified data errors or inconsistencies in a timely manner.
  • Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.
  • Uses a variety of computer applications such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS).
  • Instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
  • Works within a team environment; supports peers in meeting goals and deadlines;
  • Flexible and handles multiple tasks, works under pressure; and copes with frequently changing projects and deadlines.
  • Identifies the principal diagnosis and principal procedure.
  • Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
  • All diagnoses and procedure codes are selected from the current version of the ICD coding system.
  • Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed.
  • Corrects coding as needed to ensure proper patient classification in the VERA program.
  • Codes inpatient professional fee services for identified inpatient admissions.
  • Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
  • Links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided. Understands the nuances of the CPT

Work Schedule: Monday-Friday 8:00am - 4:30pm MST (REMOTE)
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 53766A, 53767A, 53768A, 53769A, 53770A
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Physical Requirements: See VA Directive & Handbook 5019, Employee Occupational Health Service.

Requirements

Conditions of Employment


  • You must be a U.S. Citizen to apply for this job.
  • Selective Service Registration is required for males born after 12/31/1959.
  • Must be proficient in written and spoken English.
  • You may be required to serve a probationary period.
  • Subject to background/security investigation.
  • Selected applicants will be required to complete an online onboarding process.
  • Must pass pre-employment examination.
  • Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
  • Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.


Qualifications

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.
Experience & Education
Experience . One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure & 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 & physiology, medical coding, & 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 & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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 & education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience.
  • (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, & one 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 & 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, & health record techniques & 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:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • 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.

    Grandfathering Provision under 'Additional Information'

    Grade Determinations:

    GS-4
    Experience or Education . None beyond basic requirements.

    GS-5
    Experience . One year of creditable experience equivalent to the next lower grade level GS-04;
    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.
    AND
    Demonstrated Knowledge, Skills, & Abilities . Must demonstrate all of the following KSAs:
  • Ability to use health information technology & various office software products used in MRT (Coder) positions.
  • Ability to navigate through & abstract pertinent information from health records.
  • Knowledge of the ICD CM, PCS Official Conventions & Guidelines for Coding & Reporting, & CPT guidelines.
  • Ability to apply 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, &/or health record documentation guidelines.
  • Ability to manage priorities & coordinate work to complete duties within required timeframes, & the ability to follow-up on pending issues.
  • GS-6
    Experience. One year of creditable experience equivalent to the next lower grade level GS-05.
    AND
    Demonstrated Knowledge, Skills, & Abilities . Must demonstrate all of the following KSAs.
  • Ability to analyze the health record to identify all pertinent diagnoses & procedures for coding & to evaluate the adequacy of the documentation.
  • Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, & support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, &/or reliable.
  • Ability to apply laws & regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, & HIPAA).
  • Ability to accurately apply the ICD CM, PCS Official Conventions & Guidelines for Coding & Reporting, & CPT Guidelines to various coding scenarios.
  • Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, & skill in applying classifications to both inpatient & outpatient records based on health record documentation.
  • Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) & POA indicators to obtain correct MS-DRG.
  • GS-7
    Experience. One year of creditable experience equivalent to the next lower grade level GS-06.
    AND
    Demonstrated Knowledge, Skills, & Abilities . Must demonstrate all of the following KSAs:
  • Skill in applying current coding classifications to a variety of inpatient & outpatient specialty care areas to accurately reflect service & care provided based on documentation in the health record.
  • Ability to communicate with clinical staff for specific coding & documentation issues, such as recording inpatient & outpatient diagnoses & procedures, the correct sequencing of diagnoses &/or procedures, & the relationship between health record documentation & code assignment.
  • Ability to research & solve coding & documentation related issues.
  • Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete.
  • Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct MS-DRG.
  • GS-8
    Experience . One year of creditable experience equivalent to the next lower grade level GS-07.
    AND
    Demonstrated Knowledge, Skills, & Abilities . Must demonstrate all of the following KSAs:
  • Ability to analyze the health record to identify all pertinent diagnoses & procedures for coding & to evaluate the adequacy of the documentation. This includes the ability to read & understand the content of the health record, the terminology, the significance of the comments, & the disease process/pathophysiology of the patient
  • .Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies & procedures, & outpatient encounters, & inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services.
  • Skill in interpreting & adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, & the ability to use judgment in completing assignments using incomplete or inadequate guidelines.


  • Education

    IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

    Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/ . If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html .

    Additional information

    Applicants pending the completion of educational or certification/licensure requirements may be referred & tentatively selected but may not be hired until all requirements are met.

    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 & meet the criteria).All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, & grade held, including positive education & certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply
    This job opportunity announcement may be used to fill additional vacancies.

    Preferred Experience: 5 Years of Outpatient/Inpatient coding Experience, VERA Coding Experience is Preferred.

    References: VA Handbook 5005/122 PART II APPENDIX G57

    The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-08.

    This position is in the Excepted Service and does not confer competitive status.

    VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

    Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.

    If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application .

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