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Role Description

The Carl T. Hayden Veterans Affairs Medical Center in Phoenix, Arizona is seeking a dynamic Medical Records Technician (Coder-Inpatient) to join our Health Information Management (HIM) team! MRT (Coder-Inpatient) will analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services.
• Perform a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services.
• Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.

Work Schedule: Monday-Friday 7:00 am - 3:30 pm

Compressed/Flexible: Not Available

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• 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.
• 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.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification through AHIMA or AAPC, Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Grade Determinations: Medical Records Technician (Coder-Inpatient), GS 675-8 requires one year of creditable experience equivalent to the next lower grade level (GS-07).
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation.
• Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity.

Benefits

• Competitive salary and regular salary increases; higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA.
• 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
• Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
• Child Care Subsidy: After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs.
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance (many federal insurance programs can be carried into retirement).
• This position is telework eligible but may be required to return to the office permanently at a later date.

Physical Requirements

The majority of work will be sedentary, but standing and bending may be necessary.