This position is located in the Health Information Management (HIM) section at the White River Junction, VT VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation.
Duties include but are not limited to:
- Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
- Applies knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
- Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
- Maintains current knowledge of regulatory and policy requirements affecting coded information. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic.
- Reports incorrect documentation or codes in the electronic patient health record. Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment.
- Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
- Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
- Researches references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.
- Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
- Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
- Performs additional duties assigned by management.
Work Schedule: Monday - Friday, 8:00 am to 4:30 pm
Telework: Not Authorized
Virtual: This is not a virtual position.
Telework/Virtual/Remote Work: This position is being filled as remote (i.e., the employee will not work at a VA facility or VA-leased space). Typically, this means working from home 100%.
Functional Statement #: F03487, F03467, F03468, F03469, F03429
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
PCS Appraised Value Offer (AVO): Not Authorized
Notifications: - This position is in the Excepted Service.
- This position is a AFGE Bargaining Unit position.
Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held.
Narrative responses to the knowledge, skills and abilities (KSAs) may be required from the selectee in order to proceed with the appointment.
Starting at $35,373 Per Year (GS 00)