Medical Records Technician (Coder) - Department Of Veterans Affairs - Augusta, ME
How would you like to become a part of a team providing compassionate care to Veterans?
The VA Maine Healthcare System is seeking for two (2) Medical Records Technicians (Coders) to perform quality review of patient care documents and assigning codes specific to the type of care provided under the Business Service Line. We are an employer of choice that is the center of excellence in patient care, education and research. We value Integrity, Commitment, Advocacy, Respect and Excellence. We value you.
As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities and leadership positions at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the Nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries. VA professionals feel good about their careers and their ability to balance work and home life. VA offers generous paid time off and a variety of predictable and flexible scheduling opportunities. For more information on the Department of Veterans Affairs, go to http://www.vacareers.va.gov .
VA encourages persons with disabilities to apply. The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
Relocation Expenses and Recruitment/Relocation incentives are not authorized for this position. TRAVEL REQUIRED
Not Required RELOCATION AUTHORIZED
No KEY REQUIREMENTS
Must be U.S. Citizen.
Must pass pre-employment examination.
Must be proficient in written and spoken English.
Background and-or Security Investigation required.
Selective Service Registration is required for males born after 12/31/1959 DUTIES: Back to top
Medical Records Technician (Coder) perform quality review of patient care documents and assigning codes specific to the type of care provided. The duties include but are not limited to:
- Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services. Applies advanced 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.
- Adheres and keeps abreast of 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.
- Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- 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 record.
- Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national database.
- Corrects any identified data errors or inconsistencies in a timely manner.
- Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic medical record.
- Strictly complies with regulatory fraud and abuse guidelines and federal agency specific guidance for optimum allowable reimbursement.
- Codes diagnoses from paper forms for registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
- Incumbent works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
- Protects and maintains the privacy and confidentiality of printed and electronic files in accordance with the applicable laws and regulations on confidentiality such as the Privacy Act, the Health Insurance Portability and Accountability Act, and the Freedom of Information Act.
Work Schedule: Monday – Friday 8:00am to 4:30pm.
Functional Statement: MRT (Coder) BSL
BASIC REQUIREMENTS:
Citizenship.
Citizen
of the United States. (Non-citizens may be appointed when it is not possible to
recruit
qualified candidates in accordance with chapter 3, section A, paragraph
3g, this part.)
Experience.
Two
years of experience that demonstrates the applicant’s ability to perform the
work, or provides familiarity with the work. Six months of the required 2 years
of experience must have provided the knowledge, skills, abilities, and other
characteristics (KSAs) needed to perform MRT work. OR,
QUALIFICATIONS REQUIRED: Back to top
Education.
Successful
completion of an associate’s degree with a major field of study in medical
record technology/health information technology which was accredited by the
American Health Information Management Association (AHIMA) at the time the
program was completed. OR,
Experience/Education
Combination. Equivalent
combinations of experience and education are qualifying. The following
educational/training substitutions are appropriate in this provision for
combining education and experience:
(a) Successful completion of an associate’s
degree in a field of study other than medical records/health information will
substitute for 18 months of the required experience.
(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 1 year of experience.
(c) Successful completion of a post-high
school course of study in medical record technology, which includes courses in
anatomy, physiology, and medical record techniques and procedures, may
substitute on a month-for-month basis for up to 1 year of experience.
(d) Successful completion of post-high
school courses for medical administrative personnel, obtained in a closely
supervised training program given by the Armed Forces, may be substituted for
experience on a month-for-month basis for up to 6 months provided the training
program included courses in anatomy, physiology, and medical record techniques
and procedures.
English
Language Proficiency. MRTs must be proficient in spoken and written English
in accordance with chapter 2, section D, paragraph 5a, this part.
Preferred
Experience: Medical records coding experience in large and complex organizational structure with hospital based outpatient services,
acute medical and surgical wards, intensive care units, extended care services,
Nursing Home Care units, Spinal Cord Injury Unit, Domiciliary, Home Health,
Community Based Outpatient Clinics, Telemedicine, Dialysis, Radiation Oncology,
and various independent research programs. Ability to provide medical records
coding training to medical residents and allied health professionals in
nursing, pharmacy, social work, public health, dentistry, and other health care
programs.
IN DESCRIBING YOUR EXPERIENCE,
PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR
EXPERIENCE.
GRADE DETERMINATIONS:
GS-4
Experience
or Education. None
beyond basic requirements.
In
addition, the candidate must demonstrate the following k nowledge, skills, and abilities:
1.
Basic knowledge of medical terminology;
2.
Basic knowledge of disease processes and human anatomy;
3.
Basic knowledge of medical record/health information guidelines, techniques,
and procedures;
4.
Knowledge of the medical and legal significance of medical records
GS-5
Experience.
In
addition to the basic requirements, at least 1 year of experience at the next
lower grade level and must fully meet the KSAs at that level. OR,
Education.
Successful
completion of a baccalaureate degree from an accredited college or university
with a major field of study in medical record technology/health information
technology or a related degree with courses related to medical record
technology sufficient to evidence the core competencies identified.
In
addition, the candidate must demonstrate the following k nowledge, skills, and abilities:
1.
Ability to apply knowledge of medical terminology, human
anatomy/pathophysiology, and disease processes sufficient to appropriately
file, locate, and disclose health information;
2.
Ability to correctly apply a practical knowledge of laws and regulations
related to the confidentiality of health information and the release of
information from medical records;
3.
Knowledge of the internal organization of medical records and medical record
references and procedures as appropriate to the position.
4.
Ability to use health information software appropriate to the position, such as
the electronic patient record, record tracking systems, chart deficiency
systems, coding and abstracting systems, release of information systems,
document scanning technology, electronic spreadsheets, transcription systems,
encoder products, electronic encounter forms, database software, etc.
GS-6
Experience. One year of experience
comparable to the next lower level and must fully meet the k nowledge, skills, and abilities at
that level. In addition, the candidate must demonstrate the following k nowledge, skills, and abilities:
1. Ability to apply knowledge of medical terminology, human
anatomy/pathophysiology, and disease processes to fully understand the content
of a patient record;
2. Ability to navigate efficiently through the paper and
electronic medical record to find needed information;
3. 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;
4 . If assigned to medical record analysis, ability to
judge whether medical records contain sufficient information for regulatory
requirements; are acceptable as legal documents; are adequate for continuity of
patient care; and support education and research needs. This includes the
ability to take appropriate actions if medical record contents are not
adequate; accurate, timely, and/or reliable;
5. Ability to apply laws and regulations on the
confidentiality of health information (e.g., Privacy Act, Freedom of
Information Act, Health Insurance Portability and Accountability Act (HIPAA);
6. If assigned to a tumor registry position, ability to apply
guidelines and standards for the maintenance of an approved tumor registry; and
7. If assigned to a medical coding position, comprehensive
knowledge of classification systems, such as current versions of International
Classification of Diseases, Current Procedural Technology, the Systematized
Nomenclature of Medicine or Healthcare Common Procedure Coding System, and
skill in applying coding knowledge.
GS-7
Experience.
One
year of experience comparable to the next lower grade level and must fully meet
the KSAs at that level including those for tumor registry or coder assignments
if applicable. In addition, the candidate must demonstrate the following
knowledge, skills and abilities:
1.
Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED
or HCPCS, and skill in applying coding knowledge to a wide range of specialty
areas;
2.
Knowledge of Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS)
and/or VHA medical record documentation requirements;
3.
Ability to communicate with clinical staff on coding and documentation issues
such as recording inpatient and outpatient diagnoses and procedures, the use of
encounter forms, the correct sequencing of diagnoses/ procedures, and/or the
relationship between health care documentation and code assignment;
4.
Ability to research and solve complex questions related to coding and
documentation, such as adequate health information documentation, coding,
billing, resident supervision, etc.; and
5.
Skill in reviewing and correcting system or processing errors, reviewing
transmission reports, and ensuring all assigned episodes are complete and
accurate as appropriate to the duties assigned.
GS-8
Experience.
One
year of experience comparable to the next lower grade level for the appropriate
assignment area and must fully meet the KSAs at that level.
Medical
Record Technician (Medical Coder) Positions. This is considered to be the full
performance level for this assignment. Certification at this grade level is
highly desired. In addition, the candidate must demonstrate the following
knowledge, skills and abilities:
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.
Skill in reviewing medical record documentation and assigning current versions
of the classification systems required in the current position, such as ICD and
CPT; and
3.
Advanced knowledge of the full scope of coding and abstracting including
inpatient discharges, surgical cases, diagnostic studies and procedures,
outpatient encounters, and inpatient professional fees for a highly diversified
range of specialties and subspecialties, such as orthopedics, neurosurgery,
cardiology, gastroenterology, plastic surgery, spinal cord injury, blind
rehabilitation, anesthesia, acute and long term psychiatry including addiction
treatment, hospice, ambulatory surgery, and other types of care.
Experience refers
to paid and unpaid experience, including volunteer work done through National
Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g.,
professional; philanthropic; religions; spiritual; community; student; social).
Volunteer work helps build critical
competencies, knowledge, and skills and can provide valuable training and
experience that translates directly to paid employment. You will receive credit for all qualifying
experience, including volunteer experience.
References:
Input applicable VA Handbook 5005/15, Part II,
Appendix G-35 of VA Qualification Standard. http://vaww.va.gov/OHRM/Directives-Handbooks/Documents/5005.pdf
PLEASE NOTE: Education must be accredited by an
accrediting institution recognized by the U.S. Department of Education in order
for it to be credited towards qualifications (particularly positions with a
positive education requirement.) Therefore, applicants must report only
attendance and/or degrees from schools accredited by accrediting institutions
recognized by the U.S. Department of Education. Applicants can verify
accreditation at the following website: http://www.ed.gov/admins/finaid/accred/index.html All education claimed by
applicants will be verified by the appointing agency accordingly. If you
are using foreign education to meet qualification requirements, you must send a
Certificate of Foreign Equivalency with your transcript in order to receive
credit for that education.
Physical
Requirements: The work is sedentary, however, there may be some
walking, standing, bending, carrying of light items such as papers, books. No
special physical demands are required to perform the work.
Veterans’
Preference: When
applying for Federal Jobs, eligible Veterans should claim preference on the
Occupational Questionnaire in the section provided and provide a legible copy
of your DD214(s) and/or documentation related to your active duty service which
shows dates of service, character of service (honorable, general, etc.), or
dates of impending separation.
Additionally,
disabled veterans and others eligible for 10-point preference (such as widows
or mothers of eligible Veterans) must also submit an SF-15 “Application
for 10 Point Veterans Preference” with required proof as stated on the
form. For more information, please review the information for disabled
Veterans in the application checklist or visit http://www.fedshirevets.gov/job/vetpref/index.aspx .
HOW YOU WILL BE EVALUATED:
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.
Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
Note : 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 Step 1 to GS-8 Step 10. The Professional Standards Board (a peer-review group) will review the selected candidate’s education and experience and recommend the grade and step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate. BENEFITS: Back to top
VA offers a
comprehensive benefits package. This
link provides is an overview of the benefits currently offered: http://www.vacareers.va.gov/why-choose-va/benefits/index.asp .
OTHER INFORMATION:
This job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
0 comments:
Post a Comment