Medical Records Technician (Coder-Inpatient) Job in Providence, Rhode Island – Department of Veterans Affairs



The United States government is a massive employer, and is always looking for qualified candidates to fill a wide variety of open employment positions in locations across the country. Below you’ll find a Qualification Summary for an active, open job listing from the Department of Veterans Affairs. The opening is for a Medical Records Technician (Coder-Inpatient) in Providence, Rhode Island Feel free to browse this and any other job listings and reach out to us with any questions!

Medical Records Technician (Coder-Inpatient) – Providence, Rhode Island
Veterans Affairs, Veterans Health Administration, Department of Veterans Affairs
Job ID: 193910
Start Date: 01/13/2020
End Date: 01/27/2020

Qualification Summary
To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement, 01/27/2020.
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. 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 American Health Information Management Association (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). To qualify for Medical Records Technician (Coder-Inpatient) at the GS-8 level, applicants must possess one year of experience equivalent to the next lower grade level.Demonstrated Knowledge, Skills, and Abilities. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG. In addition to the experience above, the candidate must also demonstrate all of the following KSAs: Ability to analyze the health 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 health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have an Apprentice and/or Associate Level Certification through AHIMA or AAPC.Preferred Experience: Three to Five years of direct hands-on outpatient coding. Ability to code diagnosis, surgeries and procedures utilizing ICD-10 including PCS, CPT, and HCPCS (Healthcare Common Procedure Coding System) coding systems. Ability to apply modifiers as appropriate. Thorough understanding of ICD-10 Official Coding Guidelines. Understanding of medical necessity requirements. Experience in Evaluation and Management Coding for professional services. Assignment: This is the journey level for this assignment. Outpatient MRTs(Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties. They also directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. MRTs (Coder) must abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They also query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. MRTs (Coder) ensure audit findings have been corrected and refiled. They also use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit. References: VA Handbook 5005/122, Part II, Appendix G57 Physical Requirements: The majority of work is performed in the office setting, primarily while seated. The position requires some standing, ambulation, bending and carrying of items such as training manuals. In addition, there can be increased stress due to the intensity of a patient/customer complaint or concern.

If you’d like to submit a resume or apply for this position, please contact Premier Veterans at All are free to apply!


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