Medical Records Technician

Summary This position is located in Education Service at the Central Texas Veterans Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation. Learn more about this agency Help Overview Accepting applications Open & closing dates 04/17/2024 to 04/29/2024 Salary $59,966 - $77,955 per year Pay scale & grade GS 9 Help Location 1 vacancy in the following location: Temple, TX 1 vacancy Remote job No Telework eligible Yes-Regular telework, 3 or more days a pay period, available after successful completion of orientation. Travel Required Occasional travel - You may be expected to travel for this position. Relocation expenses reimbursed No Appointment type Permanent - Work schedule Full-time - Service Excepted Promotion potential None Job family (Series) 0675 Medical Records Technician Supervisory status No Security clearance Other Drug test No Position sensitivity and risk Non-sensitive (NS)/Low Risk Trust determination process Suitability/Fitness Announcement number CAZM 24-SG Control number Help This job is open to Federal employees - Competitive service Current or former competitive service federal employees. Federal employees - Excepted service Current excepted service federal employees. Internal to an agency Current federal employees of this agency. Clarification from the agency This announcement is open to current, permanent Department of Veteran Affairs Employees, and current permanent Federal Employees. If you do not fall within that area of consideration please apply to the public announcement CAZM 24-SG Help This job is also open in another announcement to: The public Help This job is also open in another announcement to: The public Videos Help Duties Major duties include, but are not limited to: Applies comprehensive 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. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the CTVHCS. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. 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. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Expertly 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. Uses 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. Work Schedule: Monday - Friday 7:30a.m. - 4:00p.m. or 8:00a.m.- 4:30p.m Telework: Regular telework, 3 or more days a pay period, available after successful completion of orientation. Virtual: This is not a virtual position. Functional Statement : PD000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required Help Requirements Conditions of Employment 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. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details. Qualifications 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. Experience and Education: 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; 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) (Transcripts Required) OR; Education - 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; 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 (Transcripts Required): 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. 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) or (2) below: Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: Medical Records Technician-Clinical Documentation Improvement Specialist (Outpatient/Inpatient), GS-09 (Full Performance Level) Experience. At least one year of creditable experience equivalent to the GS-8 Medical Records Technician (Coder - Outpatient and Inpatient) OR; Education. An associate's degree or higher and three (3) years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records) (Transcripts Required) OR; Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement OR; Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Demonstrated Knowledge, Skills, and Abilities. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. Knowledge of anatomy and physiology, pathophysiology . click apply for full job details