Medical Records Technician

**Duties**: Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of 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. Coders directly consult with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record and may also be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). They will also enter and correct information that has been rejected, when necessary, as well as, correct any identified data errors or inconsistencies. The basic duties of the position are: - Assign codes to documented patient care encounters (inpatient) covering the full range of health care services provided by the VAMC. - 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 current versions of the International Classification of Diseases (ICD). - Adheres 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. **Work Schedule**: Monday-Friday 8:00 am - 4:30 pm **Remote**: This is remote position. (Remote refers to work performed on a full-time basis anywhere other than at a VA facility or using VA-leased space.) **Functional Statement #**:91172A **Relocation/Recruitment Incentives**: Not Authorized **Permanent Change of Station (PCS)**:Not Authorized **Fi**nancial Disclosure Report**: Not required **Requirements**: **Conditions of Employment**: - Selective Service Registration is required for males born after 12/31/1959. - Must be proficient in written and spoken English. - You may be required to serve a probationary period. - Subject to background/security investigation. - Selected applicants will be required to complete an online onboarding process. - Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). - Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details. **Qualifications**: - Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. - **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: 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure & format of a health record; **OR,**: - Education: Associate's degree from an accredited college or university recognized by the U.S. Department of Education w/ a major field of study in health information technology/health information management, or a related degree w/ 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,**: - Education: Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 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/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 that qualify for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience: (a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, and 1 year above high school, w/ minimum of 6 semester hours of health information technology cour