Medical Records Technician (Coder In/Out Patient)

These two Medical Records Technician Coder (Outpatient and Inpatient) positions are located in the Health Information Management (HIMS) Section at the VA Central Western Massachusetts Healthcare System Center in Leeds MA.

Duties

• Medical Record Technicians (Coder-Outpatient and Inpatient) 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. 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.

Duties Include But Not Limited To

• Apply knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine inpatient facility and/or professional services.
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, to ensure ethical, accurate, and complete coding.
• Selects diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
• Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
• Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database. Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed.
• Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the health record applications (VistA and CPRS) as well as the encoder product suite.

Work Schedule: 40 Hours of week, Monday-Friday, 7:30am to 4:00pm, EST

Telework: Available at the Management's discretion.

Requirements

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• You may be required to serve a probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Must pass pre-employment examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

Basic Requirements

• United States Citizenship. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f).

Qualifications

• 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.
• 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.
• 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.

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.
• This job opportunity announcement may be used to fill additional vacancies.
• VA encourages persons with disabilities to apply.