Medical Records Technician (Coder Inpatient

This position is located in the Health Information Management (HIM) section at the Durham VA Medical Center. MRTs (Coder-Inpatient) 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.

• United States Citizenship:
  Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• One year of creditable experience equivalent to the next lower grade level.

Demonstrated KSAs. In addition to the experience above, the employee must demonstrate all of the following KSAs:

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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 process/pathophysiology of the patient;
• Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services; and
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

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

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).

For more information on this qualification standard, please visit https://(Use the "Apply for this Job" box below). Standards/.

See VA Directive and Handbook 5019, Employee Occupational Health Service for requirements.