Medical Records Technician (Coder-Outpatient and Inpatient

This position is located in the Health Information Management (HIM) section at the Hershel Woody Williams 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.

• 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. DOE with a major field of study in HIT/HIM, or a related degree with a minimum of 12 semester hours in HIT/HIM (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. DOE 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.
  * See Education Section for more information.

• Experience or Education. None beyond basic requirements.
• Assignment. Employees at this level serve as entry level MRTs (Coder) and receive close supervision from more experienced MRTs (Coder).

• Experience. One year of creditable experience equivalent to the next lower grade level; OR,
• Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
• Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
  • Ability to navigate through and abstract pertinent information from health records.
  • Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
  • Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
  • Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
  • Ability to manage priorities and coordinate work to complete duties within required time frames, and the ability to follow-up on pending issues.

• Experience. One year of creditable experience equivalent to the next lower grade level.
• Assignment. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring.