Lead Medical Record Technician (Coder-Outpatient and Inpatient)

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 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 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 that indicates 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, 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). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. English Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). GRANDFATHERING PROVISION - All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:(1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.(2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.(3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.(4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.(5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met. GS-9 Experience: One year of creditable experience equivalent to the journey grade level (GS-8) of a Medical Records Technician (Coder). Demonstrated Knowledge, Skills, and Abilities: In addition to the above experience, the employee must demonstrate all the following KSAs: Ability to work with a team t provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work etc.; Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner; Ability to effectively communicate, both orally and in writing, in order to meet program objectives; Knowledge of training methods and the ability to provide training to new coding staff; Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels; and Leadership skills, including interpersonal relations and conflict resolution between employee, managers and clinical staff. Certification: Employees at this level must have a mastery level certification. Current mastery level certificates include: Certified Coding Specialist(CCS), Certified Coding Specialist-Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-09. Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation and would generally not require a pre-placement examination. This position is located in the Health Information Management (HIM) in Health Administration Service (HAS) at the Marion, IL VA Medical Center. The Lead Medical Records Technician (Coder) Outpatient and Inpatient is skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based setting., such as physician offices, group practices, multi-specialty clinics, and specialty centers.

• The Lead MRT (Coder) Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. The duties include but are not limited to: Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies. Gives on the job training to new coders and student to provide the individual with basic knowledge, skill, and ability to perform full range of routine and non-routine responsibilities. Trains and works closely with professional and administrative staff to assist in the development, maintenance and use of ICD and CPT codes to ensure accurate date capture. Conforms to standards and participate in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Center for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines. Distribute and balance the workload among employees in accordance with established workflows or job specialization, assures timely accomplishment of the assigned workload. Reviews compliance monitors with supervisors and identifies training needs. Reviews audits, trains, monitor, and completes special assignment within specified time frames. Analyze and recommends improvement in documentation systems used to provide patient care to optimize VERA workload, third party reimbursement, and to manage resources. Identifies training needs of individuals based on productivity and accuracy reports, rejects filing from billing and spot checks. Makes recommendations to supervisor concerning disciplinary actions due to insufficient performance and identifies continue education needs. Required to train others on the encoder products suite. Utilize this system in an on-going basis to perform core coding duties and audits. Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided. Has constant interaction with health care providers, evaluating, and communicating with the expectation on improving health record documentation, which will result in improved patient care and improved revenue generation. Educates providers through feedback, email queries, or informal meetings. participates in the orientation of House Staff from affiliated medical schools and other personnel needed. Other duties as assigned. Work Schedule: Monday - Friday 8:00am - 4:30pm CST Telework: Not Eligible Virtual: This position is remote work eligible and is currently exempted from return to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized