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Job Title: Lead Medical Records Technician (Coder)
Company Name: Veterans Affairs, Veterans Health Administration
Location: Cleveland, OH
Position Type: Full Time
Post Date: 02/09/2018
Expire Date: 04/10/2018
Job Categories: Computers, Software, Consulting Services, Customer Service and Call Center, Finance/Economics, Healthcare, Other, Healthcare, Practitioner and Technician, Information Technology, Installation, Maintenance, and Repair, Military, Research & Development, Medical, Energy / Utilities
Job Description
Lead Medical Records Technician (Coder)

The Northeast Ohio VA Healthcare System is recruiting for a Lead Medical Records Technician (Coder). The Lead Medical Records Technician
(Coder) will function in Health Information Management section in Patient Care Administrative Service. The Lead Medical Records Technician
(Coder) duties include:

  • Assigning codes to document patient care encounters (inpatient or outpatient) using current clinical classification systems including International Classification of Diseases (ICD), Current procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
  • Applying 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.
  • Auditing for Inpatient DRG, ICD-10 PCS, CPT Surgery Outpatient and Evaluation & Management experience that is adhering to 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.
  • Applying codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all patients into specific classes representing their clinical conditions and resource needs.
  • Monitoring ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided.
  • Providing technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
  • Insuring provider documentation is complete and supports the diagnoses and procedures coded.
  • Consulting with the professional staff for clarification of conflicting or ambiguous clinical data.
  • Searching the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
  • Utilizing the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national database.
  • Correcting identified data errors or inconsistencies in a timely manner to ensure acceptance in the national database.
  • Independently researching Coding Clinic references and other Guidelines to resolve any questionable code errors; contacts supervisor as appropriate.
  • Monitoring the status and progress of work and day-to-day adjustments in accordance with established priorities.
  • Instructing employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies.
  • Facilitating on the job training to new coders and students to provide the individual with the basic knowledge, skill, and ability to perform the full range of routine and non-routine responsibilities required.
  • Distributing and balancing the workload among employees in accordance with established workflow or job specialization, assures timely accomplishment of the assigned workload.
  • Analyzing and recommending improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources.
  • Reviewing compliance monitors and identifies training needs.
  • Reviewing, auditing, training, monitoring, and completing special assignments.
  • Identifying training needs of individuals based on productivity and accuracy reports, rejects from billing and spot checks.
  • Making recommendations concerning disciplinary actions due to insufficient performance and identifies continuing education needs.
  • Training and working closely with professional and administrative staff to assist in the development, maintenance, and usage of ICD and CPT codes to ensure accurate data capture.
  • Participating in technical evaluation and validation of health records for compliance with the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines.
Work Schedule: Monday through Friday, 8:00 am - 4:30 pm
Telework: Not Authorized
Financial Disclosure Report: Not Required
Relocation Expenses: Relocation expenses are not authorized for this position.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 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
    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
    Experience/Education Combination: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
    (a) Six 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 six 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:
  • 2 years or more of auditing experience in inpatient and outpatient coding.
  • American Health Information Management Association (AHIMA) certification as CCA, CCS, CCS-P, RHIA, RHIT, or specialty coding
  • certification.
  • AAPC Certification as CPC, CIC, COC, CRC or CPC-P or specialty coding certification.
  • Diagnosis-Related Group (DRG) and ICD-10 PCS coding and Auditing experience.
Grade Determinations:
GS-09 Specialized Experience: You must possess one year of specialized experience equivalent to the GS-08 level in the Federal Service.
Specialized experience is defined as experience which equipped you with the particular knowledge, skills, and abilities to perform successfully
the duties of the Lead Medical Record Technician (Coder), and that is typically in or related to the work of the position. Examples of specialized
experience include but are not limited to: Reviewing inpatient documentation within the health record to assign ICD codes for diagnosis,
complications, co-morbid conditions, surgery, and procedures; reviewing outpatient 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; consulting with professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record; abstracting and
sequencing codes into encoder software to obtain correct diagnosis-related group (DRG); entering and correcting information that has been
rejected; and correcting any identified data errors or inconsistencies.

References: VA Handbook 5005/79, Part II, Appendix G35

The full performance level of this vacancy is GS-09.Physical Requirements: The physical requirements of this position are concerned with the mental and physical ability of the applicant to
satisfactorily perform the duties of the proposed assignment and may include requisite laboratory and other screening as required by Federal
regulatory agencies. This position requires light lifting and carrying under 15 pounds, reaching above shoulder, use of fingers, ability to
distinguish basic colors, hearing (aid permitted), near vision correctable at 13" to 16" to jaeger 1 to 4, far vision correctable in one eye to 20/20
and to 20/40 in the other, emotional/mental stability, electrical energy, working closely with others, and working alone.

Selected applicants will be required to complete an online onboarding process.

To apply for this position, you must provide a complete Application Package which includes:

  • Resume (when listing previous employment please include month and year).
  • Your most recent SF-50 that shows title, series, and grade.
  • If you have previously held a higher grade and are applying based on that grade, you must provide a copy of the SF-50 showing you held the higher grade in addition to your last or most recent SF-50 indicating proof of status. Note: Your SF-50 must reflect the grade and step information equivalent to or greater than the grade lower than the position you are applying to. This may not always be your most recent SF-50. You may need to submit more than one SF-50.
  • If prior military service, include all copies of your DD-214 or proof of service as well as proof of disability, if applicable. You must submit your documentation showing character of discharge.
VA Form 10-2850c Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search. Not required at the time of application.

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and 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 Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx.
Qualifications & Requirements
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 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
    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
    Experience/Education Combination: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
    (a) Six 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 six 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:
  • 2 years or more of auditing experience in inpatient and outpatient coding.
  • American Health Information Management Association (AHIMA) certification as CCA, CCS, CCS-P, RHIA, RHIT, or specialty coding
  • certification.
  • AAPC Certification as CPC, CIC, COC, CRC or CPC-P or specialty coding certification.
  • Diagnosis-Related Group (DRG) and ICD-10 PCS coding and Auditing experience.
Grade Determinations:
GS-09 Specialized Experience: You must possess one year of specialized experience equivalent to the GS-08 level in the Federal Service.
Specialized experience is defined as experience which equipped you with the particular knowledge, skills, and abilities to perform successfully
the duties of the Lead Medical Record Technician (Coder), and that is typically in or related to the work of the position. Examples of specialized
experience include but are not limited to: Reviewing inpatient documentation within the health record to assign ICD codes for diagnosis,
complications, co-morbid conditions, surgery, and procedures; reviewing outpatient 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; consulting with professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record; abstracting and
sequencing codes into encoder software to obtain correct diagnosis-related group (DRG); entering and correcting information that has been
rejected; and correcting any identified data errors or inconsistencies.

References: VA Handbook 5005/79, Part II, Appendix G35

The full performance level of this vacancy is GS-09.
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Contact Information
Contact Name:
Company Name: Veterans Affairs, Veterans Health Administration
Phone Number:
Fax Number:
Contact Email:MARQUIS.BELTON@VA.GOV
Website:http://www.ecentralmetrics.com/url/?u=82499556432%2D40&r=http%3A%2F%2Fwww%2Evacareers%2Eva%2Egov%2Fjob%2Dsearch%2Fjob%2Ddetail%2Easp%3Fjob%3D308407
Company Description:

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