Medical Records Technician (Coder)
Location: Columbia Missouri
Description: Department of Veterans Affairs is currently seeking to employ Medical Records Technician (Coder) right now, this career will be placed in Missouri. More complete informations about this career opportunity kindly read the description below. Duties:
A major component of the Harry S. Truman Memorial VeteransÂ' Hospital funding is dependent on the timely, accurate and complete! capture of required abstracted data from each inpatient, surgical and ambulatory care episode of treatment. Assigns codes to documented patient care encounters (inpatient, surgical, outpatient and professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. 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.
Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-9-CM and preparing for ICD-10-CM/PCS), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnostic Related Group (DRG).
Codes inpatient professional fee services for identified i! npatient admissions in support of the Medical Care Cost Funding (MCCF) program. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided.
Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD-9-CM and CPT coding guidelines and selects proper codes using the QuadraMed nCoder+ software; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
Utilizes the facility computer system and ! software applications to correctly code, abstract, record, and transmit! data to the national VA database in Austin. Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the medical record applications (VistA and CPRS) as well as the code selection software (e.g., QuadraMed nCoder+ Suite).
Works within a team environment; flexible and handles multiple tasks; works under pressure; and copes with frequently changing assignments and deadlines.
Acts independently to monitor /audit areas with emphasis on data validation, analysis, and generation of audit outcome reports associated with the Health Care System.
Uses independent judgment in selection of codes based on medical documentation and personal coding knowledge and skills.
Must have a strong working knowledge of medical terminology, anatomy and physiology, 'disease process, treatments, diagnostic tests, medications, procedures and accepted health care services to ensure ! proper code selection.
Must possess extensive knowledge of many VistA data fields, including Patient Care Encounter (PCE), Patient Treatment File (PTF), Nuance Compliance Coding Module (CCM), and Audit Compliance Module (ACM). Must fully understand the nature of the data kept in each file and be able to enter data, process computer data output, do computer runs, and extract project-specific data.
Maintains knowledge of current information related to third party reimbursement regulations and seeks continuing education in all phases of the coding profession. Continually keeps abreast of regulatory changes affecting coding information required by the Center for Medicare and Medicaid, VHA Directives and others, as appropriate.
Incumbent 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 the use of ! electronic medical record.
Preferred knowledge of the Veterans! Equitable Resource Allocation (VERA) model of reimbursement.
Summary
Note: The full performance level of this vacancy is
Qualifications & Evaluations
GRADE DETERMINATIONS:
GS-4 - Experience or Education. None beyond basic requirements. In addition, the candidate must demonstrate the following KSAs:
•Basic knowledge of medical terminology;
•Basic knowledge of disease processes and human anatomy;
•Basic Knowledge of medical record/health information guidelines, techniques, and procedures;
•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. In addition, the candidate must demonstrate the following KSAs:
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.
Demonstrated Knowledge, Skills, and Abilities • Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes sufficient to appropriately file, locate, and disclose health information;
• 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;
• Knowledge of the internal organization of medical records and medical record references and procedures as appropriate to the position.
• 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 informa! tion systems, document scanning technology, electronic spreadsheets, tr! anscription systems, encoder products, electronic encounter forms, database software, etc.
GS-6 - Experience. One year of experience comparable to the next lower level with demonstrated Knowledge Skills and Abilities (KSAs) at that level including •Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record; •Ability to navigate efficiently through the paper and electronic medical record to find needed information; •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; •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 su! pport education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable; •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); •Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), 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 KSAs:
Assignments. Employees at this level wil! l be assigned to a specific area of medical record/health information (! tumor registry, medical coding, or medical records). They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies are described for each type of assignment as follows.
Medical Record Technician Coding Positions. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/ health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level. Since coding rules are specific to individual classification systems, knowledge of coding systems other! than the one utilized in the position for which the individual is being boarded does not automatically meet the requirements of the position. Generally, to receive credit for experience, the coder should have performed the type of coding specified as a significant portion of duties on a regular and recurring basis, and provide evidence of the core competencies identified.
•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; •Knowledge of The Joint Commission as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements; •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 documentatio! n and code assignment; •Ability to research and solve complex question! s related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and •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.
Assignments. Employees at this grade level will be assigned to a specific area of medical record/health information, e.g., tumor registry, medical coding, or medical records. They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies for the different assignments are listed with the assignment.
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 KSAs:
•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; •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 •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 incl! uding addiction treatment, hospice, ambulatory surgery, and other types of care.
References: Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
How to Apply
To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USAJOBS resume and/or other supporting documents and complete the occupational questionnaire.
It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date. To verify your application is complete, log into your USAJOBS account, https://my.usajobs.gov/Account/Login , select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspon! dence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USAJOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USAJOBS account or your application will be incomplete.
More Info
Columbia
MO
2013-09-10T01:46:11.407913
351231700
Agency Employees Only
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://w! ww.ed.gov/admins/finaid/accred/index.html All education claimed by appl! icants 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.
GS
55844
27990
1
VATA
Veterans Affairs, Veterans Health Administration
None
This job opportunity announcement may be used to fill additional vacancies.This position is in the Excepted Service and does not confer competitive status.
Per Year
H38 2013-958169JS
VA F orm 10-2850c Application for Associated Health Occupations (Available a t http://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf ) (required) .
Please use this checklist to make sure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), documentation to support Veterans Preference claims, or ICTAP/CTAP documentation (for displace! d Federal employees). You will not be contacted for additional information. Faxing Applications or Supporting Documents: You are encouraged to apply online. Applying online will allow you to review and track the status of your application. NOTE: If you applied online and your application is complete, do not fax the paper application (1203FX) as this will overwrite your prior online responses and may result in you being found ineligible. If you completed the occupational questionnaire online and are unable to upload supporting document(s):
Click the following link to view and print the occupational questionnaire View Occupational Questionnaire .
Print the 1203FX form, follow the instructions and provide your responses to the occupational questionnaire items http://www.opm.gov/forms/pdfimage/opm1203fx.pdf.
Fax the completed 1203FX form along with any supporting documents to 1-478-757-3144. Your 1203FX will serve as a cover page for your fax transmission.
! 1-Full-Time
0675-Medical Records Technician
Active
https://! ApplicationManager.gov/Login.aspx?VacancyID=958169&CheckStatus=Y
15668-Agency Employees Only
2013-10-03T02:47:43.110833
H38 2013-958169JS
After we receive your complete application package (including any required documents), your qualifications will be reviewed to decide if you meet the basic requirements. You will be notified when this decision is made.
15509-Agency Employees Only
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If you were eligible to this career, please email us your resume, with salary requirements and a resume to Department of Veterans Affairs.
If you interested on this career just click on the Apply button, you will be redirected to the official website
This career starts available on: Thu, 03 Oct 2013 13:23:57 GMT