Medical Records Technician Coder-Outpatient/Inpatient

This position is located in the VA Pacific Islands Health Care System. This position is 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.

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. Language Proficiency: This position must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).

Experience; OR Education; OR Experience & Education Combination; 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 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; Certification: You must have either (1) Apprentice/Associate Level Certification through AHIMA or AAPC; (2) Mastery Level Certification through AHIMA or AAPC; or (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determinations: Medical Records Technician (Coder-Inpatient), GS-04 (Entry Level) Experience or Education. None beyond basic requirements.

Medical Records Technician (Coder-Inpatient), GS-05 (Developmental) Experience. One 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. A copy of transcript must be submitted.

AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following 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. Medical Records Technician (Coder-Inpatient), GS-06 (Developmental) Experience. One 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. A copy of transcript must be submitted. AND Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following 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.

Medical Records Technician (Coder-Inpatient), GS-07 (Developmental) Experience. One 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. A copy of transcript must be submitted.

AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following 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. Medical Records Technician (Coder-Outpatient and Inpatient), GS-08 (Journey Level) Experience. One year of creditable experience equivalent to the next lower grade level. AND 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. ** Qualifications Continued in the Education section