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Medical Record Technician (Coder)

Company Veterans Affairs, Veterans Health Administration
Location Danville, IL
Update 7 Day ago
300
The Medical Records Technician - Coder (MRT-Coder) position is located in the Health Information Management (HIM) section at the VA Illiana Health Care System (VAIHCS). MRT Coder is responsible for analyzing and abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. MRT Coders perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Duties include but are not limited to the following:
  • Inpatient coding includes assignment ofICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures.
  • Outpatient coding includes comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and completions, and CPT codes for surgeries, procedures and evaluation and management services, as well as equipment.
  • Consults with professional staff for clarification of abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG).
Work Schedule: Monday - Friday (7:30a-4:00p)
Functional Statement Title/#: Medical Record Technician (coder)
To qualify for this position, applicants must meet all requirements by the closing date of this announcement: Tuesday, October 03, 2017

Basic Requirements:
  • Citizenship. Citizen of the United States.
  • Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.
OR
  • Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).
OR
  • Experience and Education. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience: (a) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and 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 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.
  • Physical Requirements. See VA Directive and Handbook 5019.
  • English Language Proficiency. MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
Preferred Experience: Ability toapply, interpret and analyze laws and regulations related to the disclosure of health information. Experience educating requesters on requirements for submitting requests for health information; completion of requests for health information in accordance with applicable laws and regulations.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met indetermining the grade of candidates.

GS-04 Entry Level:
None beyond basic requirements.

GS-05 Developmental Level:
Experience: One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology. Employees at this grade level serve as developmental MRT coders and receive guidance from more experience staff members for more complex coding procedures.
You will be rated on the following Knowledge, Skills, and Abilities based on your application for this position: Please make sure that each is addressed in detail in the body of your resume .
1. Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.)
2. Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines.
3. Ability to manager priorities and coordinate work in order to complete duties within required time frames and ability to follow-up on pending issues.

GS-06 Developmental Level 2:
Experience: One year if experience equivalent to the next lower grade level. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring. Coders may perform either inpatient or outpatient coding duties or may perform a combination of inpatient and outpatient coding.
You will be rated on the following Knowledge, Skills, and Abilities based on your application for this position: Please make sure that each is addressed in detail in the body of your resume .
1. Ability to navigate through health records to find needed information.
2. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines.
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HealthInsurance Portability and Accountability Act (HIPAA));
4. Comprehensive knowledge of classification systems, such as current versions of International Classification of Disease (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation.

GS-07 Developmental Level 3:
Experience: One year if experience equivalent to the next lower grade level. Employees at this grade level serve in as developmental MRT coders and receiveminimal monitoring. Coders may perform either inpatient or outpatient coding duties or may perform a combination of inpatient and outpatient coding.
You will be rated on the following Knowledge, Skills, and Abilities based on your application for this position: Please make sure that each is addressed in detail in the body of your resume .
1. Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record.
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment.
3. Ability to research and solve coding and documentation related issues.
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work in complete.
GS-08 Full Performance Level: Experience: One year if experience equivalent to the next lower grade level. This the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICK codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services. Directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters and corrects information that has been reflected, when necessary. Corrects any identified data errors of inconsistencies.

Physical Requirements: Occasional lifting under20 lbs.; near & far vision correctable; walking and standing (up to 1 hour); kneeling, bending, climbing, stooping (up to .5 hour); rapid mental & muscular coordination simultaneously; depth perception; distinguish basic & shades of colors; hearing (aid permitted); sitting; simple grasping; and repetitive action for up to 7 hours.

It is your responsibility, as the applicant, to verify that information in your resume and supporting documents, whether uploaded or faxed, are received, legible and accurate. You may do so by reviewing your Application Status in USAJOBS, ensuring you have successful fax transmission (if applicable), etc.
The following documents are required . Failure to submit the required documents will result in a finding of "incomplete application" and you will not receive further consideration for this opportunity:

1. Your Resume . This must include information including:
a. Experience: Starting and ending dates of experience (month and year), hours worked per week and salary information).
b. Education: name and location of college, dates attended, and type and date of any degree earned. (If selected, official transcript will be required)
c. Licenses and/or certificates earned.
d. To ensure you are properly rated, you must make certain the required experience and knowledge, skills, and abilities (KSAs) listed in the qualifications section is addressed in detail in your resume .
2. Online Assessment Questionnaire (Occupational Questionnaire) . Click "Apply Online" and follow the prompts to complete this questionnaire. (If you are unable to complete this online see "How to apply section - If you cannot apply online" of this job announcement).
3. Unofficial transcripts. If you are selected official transcripts are required.

NOTE - Other documents may apply:
VA Form 10-2850c - Application for Associated Health Occupations. Available at the VA Forms website: http://www.va.gov/vaforms/search_action.asp?FormNo=10-2850&tkey=&Action=Search . REQUIRED PRIOR TO APPOINTMENT.
OF 306 - Declaration for Federal Employment - Available at https://www.opm.gov/forms/pdf_fill/of0306.pdf . REQUIRED PRIOR TO APPOINTMENT.
Please use this checklist to make sure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), documentation to support Veterans Preference claims, etc. You will not be contacted for additional information.

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference on the Occupational Questionnaire in the section provided and must provide a legible copy of your DD214(s) and/or required documentation related to their Veterans' preference claim. Submitted DD214(s) must show active duty service dates and character of service (honorable, general, etc.). If your DD214 is not yet available because you have not yet separated from service, you must submit official documentation detailing your service and impending date of separation.

Disabled Veterans and others eligible for 10-point preference (such as widows or mother/father of eligible Veterans) must also submit the required documentation as listed on the SF-15 "Application for 10 Point Veterans Preference" (example, letter from the Department of Veterans Affairs certifying that the Veteran has a service-connected disability of 10% or more). For more information, please review the information for disabled Veterans in the application checklist or visit http://www.fedshirevets.gov/job/vetpref/index.aspx .

Faxing Applications or Supporting Documents: You are encouraged to apply online. Applying online will allow you to review and track the status of your application. If you are unable to apply online or unable to upload your supporting documents to your online application, follow the directions located at the following site: Fax Options . The Vacancy ID of the job opportunity announcement is 2009792.

NOTE : If you applied online and your application is complete, do not fax the paper application (1203-FX) as this will overwrite your prior online responses and may result in you being found ineligible.