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Medical Records Technician - Coder
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/25/2019. 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 must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). Experience and Education: (1) Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR, (2) Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records). OR, (3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/ training substitutions are appropriate for combining education and experience: (a) 6 months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses. (b) 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 6 months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Preferred Experience: RHIT, CCS or Coding License Certification preferred. Inpatient and outpatient coding experience preferred. Grade Determinations: (1) GS-4 MRT(Coder) Entry Level (a) Experience or Education. None beyond basic requirements. (b) Assignment. Employees at this level serve as entry level MRT coders and receive close supervision from more experienced MRT Coders. (2) GS-5 MRT(Coder) Developmental Level 1 (a) Experience. One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology. (b) In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.); 2. Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and 3. Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues. (3) GS-6 MRT (Coder) Developmental Level 2 (a) Experience. One year of experience equivalent to the next lower level. (b) In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Ability to navigate through health records to find needed information; 2. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines; 3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and 4. Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation. (4) GS-7 MRT (Coder) Developmental Level 3 (a) Experience. One year of experience equivalent to the next lower grade level. (b) In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record; 2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment; 3. Ability to research and solve coding and documentation related issues; and 4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. (5) GS-8 MRT (Coder) Full Performance Level (a) Experience. One year of experience equivalent to the next lower grade level. (b) In addition to the experience above, the candidate must demonstrate the following KSAs: 1. Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient; 2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and 3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines. (c) Assignment. This is considered to be the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services. Directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies. References: VA Handbook 5005, Part II, Appendix G35, Medical Record Technician Qualification Standard, GS-675, available in the local Human Resources Office. The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8. Physical Requirements: Light lifting, under 15 lbs., Light carrying, under 15 lbs., Pushing, Reaching above shoulders, Use of fingers, Walking, Standing, Kneeling, Repeated bending,, Climbing, Both legs required, Ability for rapid mental and muscular coordination simultaneously, Both eyes required, Depth perception, Ability to distinguish basic colors, Hearing (aid permitted).