Medical Records Technician (Coder- Inpatient)

Location

United States

Posted

5 days ago

Salary

$36.4K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Medical Records Technician (Coder- Inpatient)

VA Northeast Ohio Healthcare System

Role Description The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder-Inpatient) position. The Medical Records Technician (Coder-Inpatient) is located in the Health Information Management Services (HIMs) section within Patient Care Administrative Service. - Reviewing record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). - Using various computer applications to abstract records, assign codes, and record and transmit data. Ensuring audit findings have been corrected and refiled. - Assigning codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. - Maintaining current knowledge of regulatory and policy requirements affecting coded information. - Consulting with a more senior coder or the supervisor to resolve issues related to conflicting or questionable clinical documentation. - Utilizing the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. - Correcting any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. - Researching references to resolve any questionable code errors; contacting a senior coder or supervisor when needed. - Identifying significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). - Establishing the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty. - Updating ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions. Qualifications - 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). - Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of 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. - Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must possess one of the following certifications: - Apprentice/Associate Level Certification through AHIMA or AAPC. - Mastery Level Certification through AHIMA or AAPC. - Clinical Documentation Improvement Certification through AHIMA or ACDIS. Requirements - Experience or Education: None beyond basic requirements for GS-4. - For GS-5: One year of creditable experience equivalent to the next lower grade level; or successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education. - For GS-6: One year of creditable experience equivalent to the next lower grade level. - For GS-7: One year of creditable experience equivalent to the next lower grade level. - For GS-8: One year of creditable experience equivalent to the next lower grade level. Benefits - Work Schedule: Monday- Friday, 8:00am - 4:30pm - Remote: This position is designated as remote. Applicants must live within 50 miles of one of our facilities. - Relocation/Recruitment Incentives: Not Authorized - Permanent Change of Station (PCS): Not authorized

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