Medical Records Technician; Coder - Inpatient

Summary

This position is located in the Health Information Management (HIM) section at the Oklahoma VA Healthcare System in Oklahoma City, OK. The position currently has a Return to Office (RTO) mid‑term extension of 180 days. Remote work is currently authorized; however, candidates may be subject to return to office if policy changes or the exemption is not extended.

• Basic Requirements
  • Citizenship
  • Citizen of the United States
  • One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records
  • Or Education
    • 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, physiology, medical coding, and introduction to health records)
    • Or completion of an AHIMA‑approved coding program or other intensive coding training program of approximately one year or more that included courses in anatomy, physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding
    • The training program must have led to eligibility for coding certification or 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 of completion
  • Or Experience/Education Combination
    • Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements
• Certification
  • Must have either Apprentice/Associate Level Certification through AHIMA or AAPC
  • Mastery Level Certification through AHIMA or AAPC
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS
• Grade Level Requirements
  • Medical Records Technician (Coder‑Outpatient and Inpatient) – GS‑8 experience
  • One year of creditable experience equivalent to the next lower grade level
• Demonstrated Knowledge – Skills – and Abilities
  • Ability to analyze health records to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation
  • Ability to read and understand the content of the health record, terminology, significance of the comments, and disease process/pathophysiology
  • Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies, procedures, outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies, procedures, and inpatient professional services
  • Skill in interpreting and adapting health information guidelines that are not completely applicable or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines
• Reference
  • For more information on this qualification standard, please visit https://(Use the "Apply for this Job" box below). Standards/
• The full performance level of this vacancy is GS‑8. The actual grade at which an applicant may be selected for this vacancy is GS‑8.
• Physical requirements:
  
  In accordance with VA Handbook 5019 – Employee Occupational Health Service.

• Assign codes to documented patient care encounters (inpatient facility and/or 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.
• Apply advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and principles and practices of health services to ensure proper code selection.
• Select and assign codes from the current version of ICD, CPT, and/or HCPCS, adhering to accepted coding practices, guidelines, and conventions.
• Apply codes based on guidelines specific to certain diagnoses and procedures and other criteria used to classify patients under the Veterans Equitable Resource Allocation…