Medical Records Technician; Coder Auditor

Overview

This position is in the Health Information Management (HIM) section at the Washington DC VA Medical Center. MRTs (Coder) Auditor classify medical data from patient records in hospitals and physician settings, such as clinics and specialty centers. They analyze health records and assign codes for diagnoses and procedures using ICD-CPT-HCPCS systems. They may also provide education on coding and documentation practices.

• United States Citizenship:
  Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• English Language Proficiency:
  To be appointed under authority of 38 U.S.C.
  
  - chapter 73 or 74 - to serve in a direct patient-care capacity in VHA, applicants must be proficient in written and spoken English
• You must upload copies of your transcript to validate the education requirement
• 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 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:
  Six months of creditable experience indicating 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
• 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 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)
• Certification:
  Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) Apprentice/Associate Level Certification through AHIMA or AAPC, (2) Mastery Level Certification through AHIMA or AAPC, or (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS
• NOTE:
  
  Mastery level certification is required for all positions above the journey level; for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification
• Grade Determinations: GS-9 Medical Records Technician (Coder) Auditor
• One year of creditable experience equivalent to the GS-8 level of a MRT (Coder)
• Experience includes:
  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 comments, and the disease…