Medical Records Technician

Summary This position is located in the Health Information Management (HIM) section at the San Diego 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. Responsibilities The journey level Medical Records Technician (Coder-Inpatient) position incumbent selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, and/or Current Procedural Terminology (CPT) and Health Common Procedure Coding System (HCPCS) classification systems for inpatient facility and/or professional services. Major Duties includes and responsibilities included but not limited to: Performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. Independently reviews and abstracts clinical data from the record for documentation of diagnosis and procedures to ensure it is adequate and appropriate to support the assigned codes. Codes all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Abstracts, assigns, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Reviews provider health record documentation to ensure that is supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Enters and corrects information that has been rejected and when necessary, the incumbent will correct any identified data errors or inconsistencies. Ensures audit findings have been corrected and refiled. Assigns codes to documented patient care encounters (inpatient facility and/or professional services covering the full range of health care services provided by the VAMC. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes 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. Uses various computer applications to abstract records, assign codes, and record and transmit data. Work Schedule: 7:00AM
- 6:00PM, Monday-Friday Telework: Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment You must be a U.
S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. Qualifications Basic

Requirements:
United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. MRTs (Coder)