LEAD MEDICAL RECORDS TECHNICIAN (CODER)
Veterans Affairs, Veterans Health Administration
Remote or New York, NY
This position is in the Health Information Management (HIM) section of the Health Administration Service (HAS) at the James J Peters 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. Responsibilities These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. 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 and the organizational structure to ensure proper code selection. Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies. Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill and ability to perform the full range of routine and non-routine responsibilities required. Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture. Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines. Distributes and balance the workload among employees in accordance with established workflow or job specialization, assures timely accomplishment of the assigned workload. This is a Remote Position: The final pay will be determined based on the VA approved GS locality scale of the selected candidate. Work Schedule: Monday to Friday 8:00 am to 4:30 pm Compressed/Flexible: Not available Telework: Available Virtual: This is a virtual position. Position Title/Functional Statement #:LEAD MEDICAL RECORDS TECHNICIAN (CODER)/PD13601O Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required Requirements Conditions of Employment Qualifications Basic Requirements: Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) b .Experience and Education (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. (2) 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, (3) 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, (4) 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) 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. (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 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. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P),Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder(COC), Certified Inpatient Coder (CIC) f .Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. g .English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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: Lead Medical Records Technician (Coder), GS-9 Lead coder assignments can be established for any of the coder subspecialties(outpatient, inpatient, outpatient and inpatient combined). The subspecialty will be reflected in the title, e.g., Lead MRT (Coder-Outpatient). Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder), GS-8. Certification. Employees at this level must have a mastery level certification. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 1) Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc. 2) Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. 3) Ability to effectively communicate, both orally and in writing, in order to meet program objectives. 4) Knowledge of training methods and the ability to provide training to new coding staff. 5) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. 6) Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. References: VA HANDBOOK 5005/122, PART II, APPENDIX G57, revised Dec 10, 2019, MRT Coder. The full performance level of this vacancy is GS-9. Physical Requirements: Work is sedentary but also demands standing, walking, bending, twisting, and carrying light Education IMPORTANT: There is no education substitution. 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 As required by Executive Order 14043, Federal employees are required to be fully vaccinated against COVID-19 regardless of the employee's duty location or work arrangement (e.g., telework, remote work, etc.), subject to such exceptions as required by law. If selected, you will be required to be vaccinated against COVID-19 and submit documentation of proof of vaccination by November 22, 2021 or before appointment or onboarding with the agency, if after November 22. The agency will provide additional information regarding what information or documentation will be needed and how you can request of the agency a legally required exception from this requirement. When an individual fails to meet a requirement stated in the job opportunity announcement, the agency may take action up to and including rescinding the offer for an applicant or termination from service of a new employee (or removal for an employee who has accrued adverse action rights). Should an agency identify an urgent, mission-critical hiring need to onboard new staff prior to those new staff becoming fully vaccinated, the agency head may delay the vaccination requirement for selected job applicants, such that they do not need to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before appointment or onboarding with the agency. In the case of such limited delays, agencies are expected to require new hires to be fully vaccinated within 60 days of their start date and to follow safety protocols for not fully vaccinated individuals until they are fully vaccinated. This job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. 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. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members. 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.
$37k-56k yearly est.