Medical Records Technician

Location

United States

Posted

5 hours ago

Salary

$55.8K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Medical Records Technician

Carl T Hayden Veterans' Administration Medical Center

Role Description This position is located in the Health Information Management (HIM) section at the Phoenix VA Medical Center. Medical Records Technicians (Coder-Outpatient) 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. They analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. Responsibilities - Utilizes computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. - Performs audits of encounters to identify areas of noncompliance in coding. - Facilitates improved overall quality, completeness, and accuracy of coded data. - Works with staff to ensure that regulations are met, or areas of weakness are identified and reported to the appropriate supervisor for corrective action. - Selects and assigns codes from the current version of several coding systems, including the 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. - Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and the structure of the patient health record. - Responsible for performing audits of coded data, developing criteria, collecting data, graphing and analyzing results, and creating reports and communicating in writing and/or in person to appropriate leadership and groups. - Maintains statistical databases to track the results and validate the program for identifying patterns and variations in coding practices, with regular reports to the medical staff and management. Work Schedule Hours to be discussed during the interview process. Remote These approved positions are currently designated for a mid-term extension to the return to office mandate through October 2025. While these positions may be filled remotely, the employee will be required to return to the office if the mid-term extension is not continued. Therefore, all applicants must be located within 50 miles of a VA facility. Telework This position is telework eligible but may be required to return to the office permanently at a later date. Qualifications - Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. - United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - 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. - Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or ACDIS. - English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Requirements - Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. - Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters. - Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity. Physical Requirements They analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

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