Medical Record Technician (Coder Inpatient) Job in Bronx, New York – Department of Veterans Affairs

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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 Record Technician (Coder Inpatient) in Bronx, New York Feel free to browse this and any other job listings and reach out to us with any questions!

Medical Record Technician (Coder Inpatient) – Bronx, New York
Veterans Health Administration, Department of Veterans Affairs
Job ID: 586143Start Date: 04/14 / 2022End Date: 05/06/2022

Qualification Summary
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. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice / Associate Level Certification through AHIMA or AAPC.
(2) Mastery Level Certification through AHIMA or AAPC.
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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 US 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 (eg, 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 US 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 (6) 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 US 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). Grade Determinations:
MRT (Coder-Inpatient), GS-4Experience or Education. None beyond basic requirements MRT (Coder-Inpatient), GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR Education. Successful completion of a bachelor’s degree from an accredited college or university recognized by the US Department of Education, with a major field of study in health information management or a related degree with a minimum of 24 semester hours in health information management or technology. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs
-Ability to use health information technology and various office software products used in MRT (Coder) positions (eg, the electronic health record, coding and abstracting software, etc.)
– Ability to navigate through and abstract pertinent information from health records- Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
– Ability to apply knowledge of medical terminology, human anatomy / physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation
– Knowledge of The Joint Commission requirements, CMS, and / or health record documentation guidelines
– Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues MRT (Coder-Inpatient), GS-6 Experience. One year of creditable experience equivalent to the next lower grade level
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs
– Ability to analyze the health record to identify all relevant diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
– Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and / or reliable
– Ability to apply laws and regulations on the confidentiality of health information (eg, Privacy Act, Freedom of Information Act, and HIPAA)
– Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios
– Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation
– Knowledge of complication or comorbidity / major complication or comorbidity (CC / MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG) MRT (Coder-Inpatient), GS-7 Experience. One year of creditable experience equivalent to the next lower grade level
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs
– 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 MRT (Coder-Inpatient), GS-8 Experience. One year of creditable experience equivalent to the next lower grade level
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs
– Ability to analyze the health record to identify all relevant diagnoses and procedures for inpatient 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 comments, 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

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

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