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Medical Records Tech I

Us Oncology, Inc.
Rockville, MD
SCOPE: Under direct supervision, assists with organizing, sorting, and filing all incoming and outgoing patient information. Prepares charts for patient visits. Files, locates, retrieves and delivers medical records and/or electronic medical records as assigned. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards. Demonstrates an understanding of patient confidentiality to protect the patient and clinic/corporation. Responsibilities Scan and attach all internal and external correspondence and electronic medical reports into patient' medical record chart according to filing system. Pulls charts for scheduled appointments in advance according to guidelines. Ensure that all appropriate documentation for the scheduled patient visit is attached to the patient's chart. Prints, mails, and/or faxes patient chart information as requested and authorized. Documents all processes. Releases medical records information to persons or agencies according to State and Federal regulations. Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. Picks up out guides at designated locations and returns to Medical Records. Catalogue charts for storage and keeps electronic reports of those records. Submits request for chart retrieval from storage if needed to comply with a medical records request. Makes copies of dictated interval notes accordingly. Monitors physician dictation and makes sure it is completed in the EMR (electronic medical record) and alerts physicians who are behind. Keeps a record of new patients for weekly physicians OCM meetings Follows policies and procedures to contribute to the efficiency of the front office Provides back-up assistance as needed by front office staff. Sends out dictations to referring providers via manual faxing, right fax, or electronically "Direct Message" (direct message via EMR is required for MIPS. In Radiation department may convert dosimetry plans into a PDR of zip file when a patient transfers to another facility for treatment. Logs FMLA/Disability forms for provider completion. Will mail or fax forms and contact patient once completed. Sends outgoing faxes and distributes incoming faxes. Prepares correspondence, memos, forms and other typing as requested by supervisor. Qualifications High school diploma or equivalent required. Position is entry level and requires 0-3 years' experience, preferably in a medical office setting. Previous experience in a medical records' experience preferred. Knowledge of electronic health record systems. Time Management, Organization, Attention to Detail and Quality Focus skills needed.High school diploma or equivalent required. Position is entry level and requires 0-3 years' experience, preferably in a medical office setting. Previous experience in a medical records' experience preferred. Knowledge of electronic health record systems. Time Management, Organization, Attention to Detail and Quality Focus skills needed.Scan and attach all internal and external correspondence and electronic medical reports into patient' medical record chart according to filing system. Pulls charts for scheduled appointments in advance according to guidelines. Ensure that all appropriate documentation for the scheduled patient visit is attached to the patient's chart. Prints, mails, and/or faxes patient chart information as requested and authorized. Documents all processes. Releases medical records information to persons or agencies according to State and Federal regulations. Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. Picks up out guides at designated locations and returns to Medical Records. Catalogue charts for storage and keeps electronic reports of those records. Submits request for chart retrieval from storage if needed to comply with a medical records request. Makes copies of dictated interval notes accordingly. Monitors physician dictation and makes sure it is completed in the EMR (electronic medical record) and alerts physicians who are behind. Keeps a record of new patients for weekly physicians OCM meetings Follows policies and procedures to contribute to the efficiency of the front office Provides back-up assistance as needed by front office staff. Sends out dictations to referring providers via manual faxing, right fax, or electronically "Direct Message" (direct message via EMR is required for MIPS. In Radiation department may convert dosimetry plans into a PDR of zip file when a patient transfers to another facility for treatment. Logs FMLA/Disability forms for provider completion. Will mail or fax forms and contact patient once completed. Sends outgoing faxes and distributes incoming faxes. Prepares correspondence, memos, forms and other typing as requested by supervisor.
11d ago

Senior Medical Records Technician

Children's National Medical Center
Silver Spring, MD
The SR Medical Records Tech will be responsible to review and analyze inpatient and ambulatory surgery medical records. Will review medical records for accuracy of pertinent documents, completeness of the physician signatures and other medical professional data entries. Will collaborate with the Medical Staff Office to report medical record deficiencies. Support the medical staff in the completion of the medical record and facilitate medical record availability. Minimum Education
High School Diploma or GED (Required)

Minimum Work Experience

2 years Experience in processing and/or maintenance of medical records. (Required)

Required Skills/Knowledge

Strong knowledge of medical record content and identification of documents is required.

Must be reliable and trustworthy, maintaining strict confidentiality of sensitive information.

Demonstrates excellent communication skills and the ability to problem solve.

Presents self in a professional manner at all times.

Exhibits confidence and courtesy when addressing the medical staff.

Ability to meet quality and quantity productivity standards set by the medical records industry .

Demonstrates proficiency in all clerical functions of medical records management.

Demonstrated competency in computer skills and ability to operate in a windows environment such as Microsoft Office and Word.

All job requirements listed indicate the minimum level of knowledge, skills, and abilities necessary to perform the job proficiently.

This job description is not to be construed as an exhaustive statement of duties, responsibilities, or requirements.

Employees will be required to perform any other job-related instructions given by their supervisor , subject to reasonable accommodation.

Functional Accountabilities

Medical Records Analysis

* Review discharged patient medical records for completeness and accuracy, based on hospital policy and accreditation and regulatory standards.
* Input incomplete data elements into delinquency database.
* Facilitate medical record availability for physician completion and retrieve medical records; contact physicians to inform them of the availability of the medical record for review and signature; re-review the medical record following physician review and signature activity.
* Monitor database to identify physicians with incomplete medical records; draft and send physician an incomplete medical record notification letter .
* File operative reports in the medical record.
* Perform clinical pertinence review of medical records per hospital policy and procedures; prepare medical record deficiency reports as needed by management.

Teamwork

* Collaborate with co-workers in the completion of daily of assignments.
* Contribute to the overall team spirit of the HIM Department.

Education/ Professional Development

* Seek educational opportunities related to medical records review and analysis.
* Participate in educational/in-service offering presented by the Human Resources Department.

Customer Service

* Participate in the CNMC's customer service education program.
* Extend assistance to all customers of the HIM Department.

Organizational Accountabilities

Organizational Commitment/Identification

* Partner in the mission and upholds the core principles of the organization
* Committed to diversity and recognizes value of cultural ethnic differences
* Demonstrate personal and professional integrity
* Maintain confidentiality at all times

Customer Service

* Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

* Demonstrate collaborative and respectful behavior
* Partner with all team members to achieve goals
* Receptive to others' ideas and opinions

Performance Improvement/Problem-solving

* Contribute to a positive work environment
* Demonstrate flexibility and willingness to change
* Identify opportunities to improve clinical and administrative processes
* Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

* Use resources efficiently
* Search for less costly ways of doing things

Safety

* Speak up when team members appear to exhibit unsafe behavior or performance
* Continuously validate and verify information needed for decision making or documentation
* Stop in the face of uncertainty and takes time to resolve the situation
* Demonstrate accurate, clear and timely verbal and written communication
* Actively promote safety for patients, families, visitors and co-workers
* Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
51d ago

Lead Medical records Technician (coder)

Department of Veterans Affairs
Remote or New York, NY
* Videos Videos * Duties Help Duties Summary 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. Learn more about this agency 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 Travel Required Not required Supervisory status No Promotion Potential 9 * Job family (Series) 0675 Medical Records Technician Similar jobs * Health Information Technicians * Medical Records And Health Information Technicians * Medical Records Specialists * Medical Records Technicians * Specialists, Medical Records * Technicians, Health Information * Requirements Help Requirements Conditions of Employment * You must be a U.S. Citizen to apply for this job * All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. * Selective Service Registration is required for males born after 12/31/1959 * You may be required to serve a probationary period * Subject to a background/security investigation * Must be proficient in written and spoken English * Selected applicants will be required to complete an online onboarding process * Participation in the seasonal influenza and Coronavirus Disease 2019 (COVID-19) Vaccination programs are requirements for all Department of Veterans Affairs Health Care Personnel (HCP) 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.
23d ago

Medical Records Technician (Coder-Inpatient and Outpatient) Virtual Position

Veterans Affairs, Veterans Health Administration
Remote or Ann Arbor, MI
This position is located in the Health Information Management (HIM) section at the VA Ann Arbor Healthcare System (VAAAHS). 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. Responsibilities Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC. 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. 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 and Management code to ensure ethical, accurate, and complete coding. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. 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. Consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient 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 to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts supervisor as appropriate. Utilizes a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (Vista and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes. Orients and 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. Work Schedule: Monday-Friday 8:00am to 4:30pm ( Financial Disclosure Report: Not required Requirements Conditions of Employment Qualifications BASIC REQUIREMENTS: a. Citizenship. Citizen of the United States. 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. OR, (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). c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675series 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. GRADE DETERMINATIONS: (1) GS-4 MRT (Coder-Outpatient and Inpatient) - Entry Level: (a) Experience or Education. None beyond basic requirements. (b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder). (2) GS-5 MRT (Coder-Outpatient and Inpatient) Developmental Level 1: (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR (b) 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. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. 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.). 2. Ability to navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. 4. 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 5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. (d) Assignment. Employees at this grade level serve as developmental level 1MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. (3) GS-6 MRT (Coder-Outpatient and Inpatient) Developmental Level 2: (a) Experience. One year of experience equivalent to the next lower level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). 4. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. 5. Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation. 6. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct MS-DRG. (c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring. (4) GS-7 MRT (Coder-Outpatient and Inpatient) Developmental Level 3: (a) Experience. One year of experience equivalent to the next lower grade level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Skill in applying current coding classifications to a variety of inpatient and outpatient 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 outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record 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 is complete. 5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG. (c) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. *(PLEASE CONTINE TO THE EDUCATION SECTION FOR THE GS-8 MRT GRADE DETERMINATIONS)* Education * Additional Information from the qualification section: (5) GS-8 MRT (Coder-Outpatient and Inpatient) Full Performance Level: (a) Experience. One year of experience equivalent to the next lower grade level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. 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. 2. 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. 3. 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. (c) Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. 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). 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 Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. 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.
17d ago

Medical Records Technician (Coder-Inpatient and Outpatient) Virtual Position

Veterans Health Administration
Remote or Ann Arbor, MI
BASIC REQUIREMENTS: a. Citizenship. Citizen of the United States. 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. OR, (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). c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675series 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. GRADE DETERMINATIONS: (1) GS-4 MRT (Coder-Outpatient and Inpatient) - Entry Level: (a) Experience or Education. None beyond basic requirements. (b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder). (2) GS-5 MRT (Coder-Outpatient and Inpatient) Developmental Level 1: (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR (b) 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. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. 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.).
2. Ability to navigate through and abstract pertinent information from health records.
3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
4. 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
5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. (d) Assignment. Employees at this grade level serve as developmental level 1MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. (3) GS-6 MRT (Coder-Outpatient and Inpatient) Developmental Level 2: (a) Experience. One year of experience equivalent to the next lower level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
4. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
5. Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
6. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct MS-DRG. (c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring. (4) GS-7 MRT (Coder-Outpatient and Inpatient) Developmental Level 3: (a) Experience. One year of experience equivalent to the next lower grade level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the
following KSAs: 1. Skill in applying current coding classifications to a variety of inpatient and outpatient 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 outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record 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 is complete.
5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG. (c) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. *(PLEASE CONTINE TO THE EDUCATION SECTION FOR THE GS-8 MRT GRADE DETERMINATIONS)*
18d ago

Medical Records Technician Dumfries

Spectrum Healthcare Resources
Dumfries, VA
Spectrum has an opportunity for a civilian Medical Records Technician at the Family Health Center Dumfries, VA. We provide out-patient clinic services for enlisted and retired military personnel in association with Ft. Belvoir Community Hospital.
The Medical Records Tech provides services in support of patient care and treatment.

Essential Functions:

Assemble patients' health information, making sure that patients' initial medical charts are complete, that all forms are completed and properly identified and authenticated, and that all necessary information is in the computer.

Communicate regularly with physicians and other health care professionals to obtain additional information, if necessary.

Follow procedures for release of medical information and correspondence requests according to the clinic policy, state and federal statutes and laws.

Manage the patients chart by filing, clinical papers and results.

Pull all charts for same and next day appointments.

Performs a variety of receptionist and other clerical duties in support of patient care for the family practice, or like clinic, in FHC's. This will include but not limited to open access scheduling and assist in creating a patient-centered health clinic.

Verifies patient information in CHCS. If information is incorrect, updates information to include Other Health Insurance (OHI).

Ensures privacy and security of all patient health information (PHI).

Be crossed trained together with Appointment Clerks and Receptionists to ensure vacancies are covered.

Assist with other duties as assigned and needed.

Full Name: First Last: Sue Davis

ID: 2021-18381

Recruiter Phone: 703-225-1403

Direct phone number: 7032251403

Facility: Belvoir Health Centers - Dumfries Clinic

Email: Susan_Davis@spectrumhealth.com

External Company Name: Spectrum Healthcare Resources

External Company URL: www.spectrumhealth.com

Telecommute: No
60d+ ago

Medical Records Tech - Full-time

Frederick Memorial Healthcare System
Frederick, MD
The Medical Records Tech position preps, scans, indexes and performs quality assurance for all incoming reports and records in paper format. Performs a variety of duties related to the processing and analysis of all inpatient and outpatient records. Conducts retrospective review to ensure compliance with regulatory and accreditation requirements for accurate documentation. Facilitates completion of Death Certificates and emergency release of information to other facilities.
Required: High School Diploma or GED is required with an Associate's Degree in Medical Office Technology, Medical Office Systems, Medical Secretarial Science or related field or equivalent combination of education and experience preferred. RHIT preferred. Scanning experience preferred. A minimum of two years of Medical Records experience is preferred.
60d+ ago

Healthcare Technology Solutions - Emergency Department EMR Optimization (Epic ASAP) - Senior Consultant

Guidehouse
Washington, DC
Guidehouse is a leading global provider of consulting services to the public and commercial markets with broad capabilities in management, technology, and risk consulting. We help clients address their toughest challenges and navigate significant regulatory pressures with a focus on transformational change, business resiliency, and technology-driven innovation. Across a range of advisory, consulting, outsourcing, and digital services, we create scalable, innovative solutions that prepare our clients for future growth and success. The company has more than 10,000 professionals in over 50 locations globally. Guidehouse is a Veritas Capital portfolio company, led by seasoned professionals with proven and diverse expertise in traditional and emerging technologies, markets, and agenda-setting issues driving national and global economies. For more information, please visit: www.guidehouse.com.
Responsibilities

As a an Emergency Room EMR (Epic ASAP) Optimization Senior Consultant on our Health Technology Solutions team, you will lead and/or participate in operational and financial improvement efforts by optimizing clinical and operational emergerncy department workflows using appropriate process improvement tools tailored to individual client needs. Clients can include large, medium, and small health systems as well as independent provider practices. Incumbent will also recommend and help implement improvements to Electronic Health Record usage to enhance efficiency, productivity, and patient/provider workflow. Your time and effort will focus on both client delivery as well as internal solution development aligned to relevant core priorities among clinical, operational, and/or revenue cycle products. You will leverage technical expertise to partner with relevant internal stakeholders and product owners to tech enable prioritized solutions.

Some project work will be stand-alone while others are embedded in larger, more comprehensive health system transformations requiring effective coordination with colleagues and other work teams. In either case, working with internal team members and multiple client stakeholders is essential.

Responsibilities:

Optimization of Ambulatory Clinic Workflows and Operations: • Work with client and other Guidehouse staff to document current state operational inefficiencies, bottlenecks, and pain points to identify opportunities for improvement • Work with client and other Guidehouse staff to document opportunities to enhance Epic ASAP to support improved clinic efficiency, provider productivity, and patient experience workflows and reporting • Work directly with client staff to implement leading practice clinic workflows, including but not limited to patient check-in, rooming, care documentation, and check-out • Establish and maintain relationships with key client stakeholders to instill confidence in subject matter expertise and in project success • Proactively seek out opportunities to tech enable relevant clinical, operational, and/or revenue cycle solutions and advance market-leading product delivery

Project Management/Oversight: • Draft, review, and coordinate relevant final deliverable coordination within client or internal project scope • Establish and maintain project structure to meet timelines, milestones, and deliverables • Demonstrated ability to plan, set priorities, organize, and coordinate with other workstreams to support larger internal / external project goals and objectives • Develop communication vehicles and materials to keep client and internal Guidehouse stakeholders informed on project and internal solution development progress and risks • Perform other project related duties as assigned by the engagement manager, or internal solution development related duties as assigned by the solution leader

Qualifications

Required: • A minimum of a bachelor's degree from an accredited university • A minimum of three (3) years demonstrated experience leading operational and financial improvement efforts within the emergency department healthcare setting • A minimum of three (3) years' experience with technical and/or operational workflow optimization • A minimum of three (3) years of in-depth experience working with electronic health records, particularly within Epic emergency department applications • Experience successfully managing multiple projects simultaneously • Strong project management background and understanding of project management processes • A minimum of (3) years consulting or relevant healthcare industry experience

Preferred: • Master's degree in Business or Healthcare Administration • Formal, advanced certification in process improvement methodologies; Six Sigma, LEAN, PDCA, etc. • Ability to create custom, client ready presentation materials in PowerPoint, Excel, Tableau, and other formats as required

• Epic ASAP certification highly desired

Additional Requirements

+ The successful candidate must not be subject to employment restrictions from a former employer (such as a non-compete) that would prevent the candidate from performing the job responsibilities as described.

+ This role is available virtually from PST, CST or EST time zones.

Disclaimer

About Guidehouse

Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.

Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.

If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com . All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.

Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.

Rewards and Benefits

Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

+ Medical, Rx, Dental & Vision Insurance

+ Personal and Family Sick Time & Company Paid Holidays

+ Position may be eligible for a discretionary variable incentive bonus

+ Parental Leave and Adoption Assistance

+ 401(k) Retirement Plan

+ Basic Life & Supplemental Life

+ Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts

+ Short-Term & Long-Term Disability

+ Tuition Reimbursement, Personal Development & Learning Opportunities

+ Skills Development & Certifications

+ Employee Referral Program

+ Corporate Sponsored Events & Community Outreach

+ Emergency Back-Up Childcare Program
43d ago

Medical Records Technician (Coder-Outpatient and Inpatient) Virtual Position

Veterans Affairs, Veterans Health Administration
Remote or Ann Arbor, MI
This position is located in the Health Information Management (HIM) section at the VA Ann Arbor Healthcare System (VAAAHS). 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. Responsibilities Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC. 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. 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 and Management code to ensure ethical, accurate, and complete coding. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. 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. Consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient 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 to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts supervisor as appropriate. Utilizes a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (Vista and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes. Orients and 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. Work Schedule: Monday-Friday 8:00am to 4:30pm (Virtual Position) Financial Disclosure Report: Not required Requirements Conditions of Employment Qualifications BASIC REQUIREMENTS: a. Citizenship. Citizen of the United States. 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. OR, (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). c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675series 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. GRADE DETERMINATIONS: (1) GS-4 MRT (Coder-Outpatient and Inpatient) - Entry Level: (a) Experience or Education. None beyond basic requirements. (b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder). (2) GS-5 MRT (Coder-Outpatient and Inpatient) Developmental Level 1: (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR (b) 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. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. 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.). 2. Ability to navigate through and abstract pertinent information from health records. 3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. 4. 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 5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. 6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. (d) Assignment. Employees at this grade level serve as developmental level 1MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. (3) GS-6 MRT (Coder-Outpatient and Inpatient) Developmental Level 2: (a) Experience. One year of experience equivalent to the next lower level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. 2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). 4. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. 5. Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation. 6. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct MS-DRG. (c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring. (4) GS-7 MRT (Coder-Outpatient and Inpatient) Developmental Level 3: (a) Experience. One year of experience equivalent to the next lower grade level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Skill in applying current coding classifications to a variety of inpatient and outpatient 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 outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record 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 is complete. 5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG. (c) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. *(PLEASE CONTINE TO THE EDUCATION SECTION FOR THE GS-8 MRT GRADE DETERMINATIONS)* Education * Additional Information from the qualification section: (5) GS-8 MRT (Coder-Outpatient and Inpatient) Full Performance Level: (a) Experience. One year of experience equivalent to the next lower grade level. (b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: 1. 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. 2. 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. 3. 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. (c) Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. 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). 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 References: VA HANDBOOK 5005/79, PART II, APPENDIX G35 dated September 5, 2014. 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-04 to GS-08. Physical Requirements: The work is primarily in a sedentary manner. However, there will be some walking, bending, reaching, stopping, lifting, carrying, and pushing of medical records or books. There will be extensive physical demand of constant typing on a keyboard on a PC. 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 view the following link for information regarding an Alternate Application.
17d ago

Medical Records Technician (Coder-Outpatient and Inpatient) Virtual Position

Department of Veterans Affairs
Remote or Ann Arbor, MI
* Videos

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* Duties

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Duties

Summary

This position is located in the Health Information Management (HIM) section at the VA Ann Arbor Healthcare System (VAAAHS). 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.

Learn more about this agency

Responsibilities

* Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC.
* 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.
* 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 and Management code to ensure ethical, accurate, and complete coding.
* Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients.
* Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
* Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
* 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.
* Consults with the professional staff for clarification of conflicting or ambiguous clinical data.
* Reports incorrect documentation or codes in the electronic patient health record.
* Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient 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 to ensure acceptance in the national VA database within established timelines.
* Researches references to resolve any questionable code errors; contacts supervisor as appropriate.
* Utilizes a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (Vista and CPRS) as well as the encoder product suite.
* Ensures current versions of all software applications are loaded and functional after any updates or changes.
* Orients and 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.

Work Schedule: Monday-Friday 8:00am to 4:30pm (Virtual Position)

Financial Disclosure Report: Not required

Travel Required

Not required

Supervisory status

No

Promotion Potential

8

* Job family (Series)

0675 Medical Records Technician

Similar jobs

* Coders, Health Information
* Health Information Coders
* Medical Records Specialists
* Specialists, Medical Records

* Requirements

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Requirements

Conditions of Employment

* You must be a U.S. Citizen to apply for this job
* All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
* Selective Service Registration is required for males born after 12/31/1959
* You may be required to serve a probationary period
* Subject to a background/security investigation
* Must be proficient in written and spoken English
* Selected applicants will be required to complete an online onboarding process
* Participation in the seasonal influenza and Coronavirus Disease 2019 (COVID-19) Vaccination programs are requirements for all Department of Veterans Affairs Health Care Personnel (HCP)

Qualifications

BASIC REQUIREMENTS:

a. Citizenship. Citizen of the United States.

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.

OR,

(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).

c. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675series 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.

GRADE DETERMINATIONS:

(1) GS-4 MRT (Coder-Outpatient and Inpatient) - Entry Level:

(a) Experience or Education. None beyond basic requirements.

(b) Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder).

(2) GS-5 MRT (Coder-Outpatient and Inpatient) Developmental Level 1:

(a) Experience. One year of creditable experience equivalent to the next lower grade level;

OR

(b) 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.

(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:

1. 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.).

2. Ability to navigate through and abstract pertinent information from health records.

3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.

4. 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

5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.

6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

(d) Assignment. Employees at this grade level serve as developmental level 1MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures.

(3) GS-6 MRT (Coder-Outpatient and Inpatient) Developmental Level 2:

(a) Experience. One year of experience equivalent to the next lower level.

(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:

1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.

2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.

3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).

4. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.

5. Comprehensive knowledge of current classification systems, such as ICDCM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.

6. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct MS-DRG.

(c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring.

(4) GS-7 MRT (Coder-Outpatient and Inpatient) Developmental Level 3:

(a) Experience. One year of experience equivalent to the next lower grade level.

(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the

following KSAs:

1. Skill in applying current coding classifications to a variety of inpatient and outpatient 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 outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record 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 is complete.

5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.

(c) Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring.

* (PLEASE CONTINE TO THE EDUCATION SECTION FOR THE GS-8 MRT GRADE DETERMINATIONS)*

Education

* Additional Information from the qualification section:

(5) GS-8 MRT (Coder-Outpatient and Inpatient) Full Performance Level:

(a) Experience. One year of experience equivalent to the next lower grade level.

(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:

1. 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.

2. 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.

3. 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.

(c) Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties.MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

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).

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.
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Average Salary For a Medical Records Technician

Based on recent jobs postings on Zippia, the average salary in the U.S. for a Medical Records Technician is $38,758 per year or $19 per hour. The highest paying Medical Records Technician jobs have a salary over $51,000 per year while the lowest paying Medical Records Technician jobs pay $29,000 per year

Average Medical Records Technician Salary
$38,000 yearly
$19 hourly
Updated October 23, 2021
29000
10 %
38000
Median
51000
90 %

Highest Paying Cities For Medical Records Technician

0 selections
CityascdescAvg. salaryascdescHourly rateascdesc
Albany, NY
$47,556
$22.86
Miami, FL
$43,842
$21.08
Rancho Cordova, CA
$43,676
$21.00
Houston, TX
$43,371
$20.85
East Orange, NJ
$42,989
$20.67
Salem, OR
$42,682
$20.52

5 Common Career Paths For a Medical Records Technician

Medical Coder

A medical coder's role is to interpret and analyze a patient's medical record and translate particular details according to the universal medical alphanumeric code. Moreover, a medical coder is primarily responsible for ensuring that the translations are accurate, as this will play a vital factor in processing insurance and receiving treatments. Aside from accuracy, it is also crucial for a medical coder to coordinate with other hospital personnel at all times, especially when there inconsistencies in the records.

Billing Specialist

Billing specialists are accounting or finance employees who are responsible for sending out billing invoices to clients. They calculate charges that their clients have incurred. They then write bills, ensure that all details are correct, and send these out to clients. They also manage payment due dates and ensure that clients are duly reminded of such deadlines. Billing specialists also manage client accounts and ensure that they are paying on time. They help identify clients who have outstanding payables and send out collection notices to them. At times, billing specialists also manage the receipt of payments to manage account records better.

Patient Service Representative

A Patient Service Representative is responsible for coordinating with patients, ensuring accuracy and satisfaction at all times. The duties of a Patient Service Representative revolves around greeting and responding to patients, offering assistance in documentation, gathering and maintaining their personal information, and even communicating with the family or guardian. They also have to collect payments and process insurance details, obtain medical history, and even keep the patients updated in various aspects. Aside from this, it is crucial for a Representative coordinate with supervisors or personnel in-charge at all times.

Specialist

Specialists are employees who are responsible for specific tasks or activities in the department they are assigned to. The actions or tasks they work on are related to their educational background or work experiences. They are usually highly skilled in specializations related to the work they are assigned to. Specialists are also highly trained on the competencies that are required of their specialty. As such, they are focused on the skills and competencies that are needed to enhance their experience in their specific field further.

Technician

Technicians are skilled professionals who primarily work with technology in different industries. They are knowledgeable about the technical aspects of the various items they work with. They are usually working with electricity or with technological advancements. Technicians may be assigned to do the construction of equipment or materials related to their field of study. They may also be assigned to conduct diagnostics and other maintenance activities to ensure that the equipment works properly. Technicians may also be required to conduct basic repairs in case of problems. It is important that technicians have good analytical skills and decision-making skills.

Illustrated Career Paths For a Medical Records Technician