Lead Medical Records Technician (Coder)
The Lead Medical Records Technician will be chiefly responsible for technical and administrative duties to ensure coded data is accurate, timely, and compliant with VHA Directives, and other requirements as well as industry standards. Duties include:
Orients and instructs new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software Ensures audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection Distributes workload to coders to assure timely coding and data entry of the Patient Treatment Files (PTF) and Patient Care Encounters (PCE) Responsible for working closely with members of the health care team to perform the coding activities with the highest degree of accuracy 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 Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by NF/SG VHS Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided Provides technical support in the areas of regulation and policy, coding requirements, resident supervision, reimbursement, workload accepted nomenclature, and proper sequencing Ensures provider documentation is complete and supports the diagnosis and procedure coded Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data Incumbent advises management and hospital staff members on policies, procedures and adequacy of record content, and on training and teaching of clerical personnel in health record functions Incumbent participates in various health record review activities 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 VA database Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines Works within a team environment; supports peers in meeting goals and deadlines Maintains a record of work accomplishments and backlogs providing a daily report to the coding manager Work Schedule:
Mon-Fri 8:
00 a.m.- 4:
30 p.m. Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement:
09/11/2020 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 (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ? 7403(f) Experience and Education:
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. OR, 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 (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records) OR, 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. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed OR, Experience/Education Combination:
Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable
Experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and 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 six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification:
Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE:
Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Grade Determinations:
GS-9 Lead Medical Records Technician (Coder)
Experience:
One year of creditable experience equivalent to the journey grade level MRT (Coder) Certification:
Mastery level certification is required for the Lead Medical Records Technician (Coder). Demonstrated Knowledge, Skills, and Abilities:
In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work,monitoring accuracy of work, etc. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. Knowledge of training methods and the ability to provide training to new coding staff. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. References:
VA Handbook 5005/122, Part II, Appendix G57 - Medical Records Technician Qualification Standard. The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is GS-09. Physical Requirements:
The work is sedentary in nature. Typically, the employee sits comfortably to complete the work. However, there may be some walking, standing, bending, and carrying of light items such as patient records supplies and letter mail.
Estimated Salary: $20 to $28 per hour based on qualifications.
Orients and instructs new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software Ensures audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection Distributes workload to coders to assure timely coding and data entry of the Patient Treatment Files (PTF) and Patient Care Encounters (PCE) Responsible for working closely with members of the health care team to perform the coding activities with the highest degree of accuracy 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 Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by NF/SG VHS Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided Provides technical support in the areas of regulation and policy, coding requirements, resident supervision, reimbursement, workload accepted nomenclature, and proper sequencing Ensures provider documentation is complete and supports the diagnosis and procedure coded Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data Incumbent advises management and hospital staff members on policies, procedures and adequacy of record content, and on training and teaching of clerical personnel in health record functions Incumbent participates in various health record review activities 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 VA database Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines Works within a team environment; supports peers in meeting goals and deadlines Maintains a record of work accomplishments and backlogs providing a daily report to the coding manager Work Schedule:
Mon-Fri 8:
00 a.m.- 4:
30 p.m. Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement:
09/11/2020 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 (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ? 7403(f) Experience and Education:
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. OR, 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 (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records) OR, 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. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed OR, Experience/Education Combination:
Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable
Experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and 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 six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification:
Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE:
Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Grade Determinations:
GS-9 Lead Medical Records Technician (Coder)
Experience:
One year of creditable experience equivalent to the journey grade level MRT (Coder) Certification:
Mastery level certification is required for the Lead Medical Records Technician (Coder). Demonstrated Knowledge, Skills, and Abilities:
In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work,monitoring accuracy of work, etc. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. Knowledge of training methods and the ability to provide training to new coding staff. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. References:
VA Handbook 5005/122, Part II, Appendix G57 - Medical Records Technician Qualification Standard. The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is GS-09. Physical Requirements:
The work is sedentary in nature. Typically, the employee sits comfortably to complete the work. However, there may be some walking, standing, bending, and carrying of light items such as patient records supplies and letter mail.
- Department:
0675 Medical Records Technician - Salary Range:
$52,905 to $68,777 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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