Medical Records Technician; Coder-Outpatient and Inpatient

This position is in the Health Information Management Service (HIMS) within the Business Office at the VA New Jersey Healthcare System located at either the East Orange or Lyons Campus. New Jersey Healthcare System is a Level 2 facility and ranks among a complex system in the Department of Veteran Affairs serving the New York/New Jersey VISN 2 Network.

Total Rewards of a Allied Health Professional

VA New Jersey Healthcare System 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.

Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes/pathophysiology, 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 one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), 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 code to ensure ethical, accurate, and complete coding. Interpreting and adapts health information guidelines that are not completely applicable to the work, or have gaps in specificity, and is able to use judgment in completing assignments using incomplete or inadequate guidelines.

Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.

Perform other duties assigned.

Monday-Friday 08:00 a.m.

-4:30 p.m.

• Recruitment Incentive (Sign-on Bonus):
  Not Authorized
• Permanent Change of Station (Relocation Assistance):
  Not Authorized
• Pay
  :
  Competitive salary and regular salary increases
• Paid Time Off
  : 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
• 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 for eligible children up to the monthly maximum of $416.66.
• Retirement
  :
  Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
• Insurance
  :
  Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).
• Telework
  :
  Not Available
• Virtual
  :
  This is not a virtual position.
• Functional Statement #: 21Z72-A
• Permanent Change of Station (PCS):
  Not Authorized