Medical Records Technician Coder Jobs (NOW HIRING)

Inpatient (Coder) select codes from current versions of ICD CM, PCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG),and/or assigning CPT/HCPCS codes.
Qualifications:BASIC REQUIREMENTS.
(a) United States Citizenship: Must be a U. S. citizen.
(b) English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English.
(c) Certification. MRT (Coder) GS-0675 must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC.

• Certified Coding Associate (CCA)
• Certified Professional Coder-Apprentice (CPC-A)
• Certified Outpatient Coding-Apprentice (COC-A)

(2) Mastery Level Certification through AHIMA or AAPC.

• 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)
• Certified Coding Specialist (CCS)

(3) Clinical Documentation Improvement

• Certification through AHIMA or ACDIS.
• Clinical Documentation Improvement Practitioner (CDIP)
• Certified Clinical Documentation Specialist

(1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding & the structure/format of a health record.
~OR~
(2) Education. An associate's degree from an accredited college/university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy & physiology, medical coding & introduction to health records).
~OR~
(3) Completion of an AHIMA approved coding program /other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, the sponsoring academic institution must be accredited by a national U.S. Department of Education accreditor/comparable international accrediting authority at the time the program was completed
(4) Experience/Education Combination. Equivalent combinations of creditable experience/education are qualifying for meeting the basic requirements.
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, and one year above high school, with a minimum of 6 semester hours..
(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists/hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical professional supervision.
GRADE DETERMINATIONS AND ASSIGNMENTS.
(1) Medical records Technician (Coder-Inpatients), GS-4
(a) Experience or Education- None beyond basic requirements above.
(2) Medical records Technician (Coder-Inpatients), GS-5
(a) Experience. One year creditable experience equivalent to the next lower grade level
~OR~
(b) Education. Successful completion of a bachelor's degree from accredited college or university.
(c) (Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs:
1. Ability to use health information technology and various office software products used in MRT (Coder) positions.
2. Ability navigate through and abstract pertinent information from health records.
3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and reporting.
4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records 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 work to complete duties within the required timeframes and the ability to follow-up on pending issues.
(3) Medical records Technician (Coder-Inpatients), GS-6
(a) Experience. One year creditable experience equivalent to the next lower grade level
(Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of 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 and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
5. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).
(4) Medical records Technician (Coder-Inpatients), GS-7
(a) Experience. One year creditable experience equivalent to the next lower grade level
(Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs:
1.Skill in applying current coding classifications to a variety of inpatient 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 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.
(5) Medical records Technician (Coder-Inpatients), GS-8
(a) Experience. One year creditable experience equivalent to the next lower grade level
(Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience, the candidate must demonstrate all of the following KSAs:
1.Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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 inpatient 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..
Physical Requirements: The work is primarily sedentary. There is walking, bending & reaching required such as for filing or locating material & carrying items such as reports, documents/supplies.Education:Preferred Experience: Inpatient ambulatory surgery coding experience.
The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to the full performance level of a GS-8.
References: VA Handbook 5005/122, Part II, Appendix G57
Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.Employment Type: OTHER