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Lead Medical Records Tech

Company: Veterans Health Administration
Location: Grand Junction
Posted on: April 9, 2021

Job Description:

Basic Requirements: U.S. citizenship: Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy Experience and Education: Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work OR Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records). OR Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:(a) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses.(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. Grade Determinations GS-09:Assignment. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and range of variety, and be performed by the incumbent at least 25% of the time. Auditors serve as experts of current coding conventions and regulations related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. Provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. Auditors work with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective action. Perform prospective coding audits and utilize results to identify processing inadequacies and re-educate coding staff where necessary. Coordinate retrospective reviews to ensure adequate auditing of coding activities. Act independently to plan, organize, direct and control areas with emphasis on data validation, analysis and generation of reports associated with the Medical Center's health information management program. This includes managing the professional health information management functions such as retrieving, reviewing and abstracting health record information. Determine quality control measures needed; initiate and implement them by use of monitors and/or continuous review. Experience. One year of experience equivalent to the next lower grade level. Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:1. Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines Physical Requirements: The work frequently requires lifting, carrying, filing, and handling of medical records, forms and supplies. Position requires sitting, standing, bending and traveling to a variety of locations within the medical center to query physician/provider for inconsistent electronic progress note documentation/encounter review. Position requires daily extended use of computer terminal for processing all phases of daily work. Incumbent must have emotional and mental stability, and be able to work closely with others. References: VA Handbook 5005-79, Part II, Appendix G35, Qualification for Medical Records Technician.

Keywords: Veterans Health Administration, Grand Junction , Lead Medical Records Tech, Healthcare , Grand Junction, Colorado

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