Medical Records Technician (Coder In/Out)

Summary

This position is located in the Health Information Management (HIM) section at the James H. Quillen VA Medical Center. MRTs (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.

Duties

• The Medical Record Technician (Coder-Outpatient and Inpatient) analyzes and abstracts patients' health records - and assigns 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
• Major duties include but not limited to: Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC
• 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
• 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
• Patient health records may be paper or electronic
• 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
• 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
• All other duties assigned Work Schedule: Monday-Friday
• 7:00am-3:30pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual - based on prior [work experience] or military service experience
• Parental Leave: After 12 months of employment - up to 12 weeks of paid parental leave in connection with the birth - adoption - or foster care placement of a child
• Child Care Subsidy: After 60 days of employment - full time employees with a total family income below $144 -000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416\.66
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available Virtual: This is not a virtual position
• Functional Statement #: 60594-F - 60592-F -60593-F -605589-F - 60590-F Permanent Change of Station (PCS): Not Authorized