Medical Records Technician (Coder)

Duties
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• Verify medical record completeness, accuracy and proper entry into computer systems.
• Identify all diagnoses and procedures associated with inpatient admission by utilizing the entire inpatient medical record, including findings on pathology, laboratory, radiology, ancillary studies and other documentation within the medical records.
• Ensure each medical record contains appropriate documentation to support the principal diagnosis, principal procedures, qualifying complications and co-morbid conditions used for the Diagnosis-Related Group (DRG) assignment.
• Assign International Code of Diseases (ICD-9-CM/ICD-10-CM) codes to each diagnosis listed, and ICD-10-PCS codes to each operation and/or procedure performed into the 3M 360 system.
• Review each recorded diagnosis and operation/procedure for accuracy and completeness.
• Determine which anatomical location is most representative and identify and properly code the causative agent for injuries and infections.
• Evaluate the sequence of diagnoses and operations/procedures to provide optimum DRG assignment.
• Engage in conversation with Physicians, Nursing and Utilization Management staff for determining the most correct DRG, procedures and complications.

Requirements
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Conditions of employment

• Appointment may be subject to a suitability or fitness determination, as determined by a completed background investigation.
• This position requires the incumbent be able to obtain and maintain a determination of eligibility for a Secret security clearance or access for the duration of employment. A background investigation and credit check are required.
• This position has mandatory seasonal Influenza vaccination requirements and is subject to annual seasonal Influenza vaccinations unless otherwise exempted for medical or religious reasons (documentation of exemption must be provided upon hire).
• Immunization screening is required. Hepatitis B immunization is required for all positions with direct patient contact. Applicants may be required to show proof of other immunizations depending on the type of position.

Qualifications

Who May Apply: US Citizens

In order to qualify, you must meet the experience requirements described below. 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; religious; spiritual; community; student; social). You will receive credit for all qualifying experience, including volunteer experience. Your resume must clearly describe your relevant experience; if qualifying based on education, your transcripts will be required as part of your application. Additional information about transcripts is in this document .

SPECIALIZED EXPERIENCE: One year of specialized experience which includes: 1) Working knowledge of anatomy and physiology, major disease process, diagnoses, surgical procedures, tests, and pharmacology; 2) Inpatient coding of medical records using International Classification of Diseases (ICD-9-CM/ICD-10-CM) for diagnosis, and ICD-10-PCS for operations and/or procedures; AND 3) Reviewing and analyzing medical records for accuracy.
This definition of specialized experience is typical of work performed at the next lower grade/level position in the federal service (GS-05).

Education

Some federal jobs allow you to substitute your education for the required experience in order to qualify. For this job, you must meet the qualification requirement using experience alone--no substitution of education for experience is permitted.

Additional information

• Male applicants born after December 31, 1959 must complete a Pre-Employment Certification Statement for Selective Service Registration.
• You will be required to provide proof of U.S. Citizenship.
• One year trial/probationary period may be required.
• Direct Deposit of Pay is required.
• Selection is subject to restrictions resulting from Department of Defense referral system for displaced employees.
• Recruitment or relocation incentives MAY be authorized for highly qualified candidates.
• Advanced In Hire (salary negotiations) MAY be authorized for highly qualified candidates.
• Multiple positions may be filled from this announcement.
• Salary includes applicable locality pay or Local Market Supplement.
• If you have retired from federal service and you are interested in employment as a reemployed annuitant, see the information in the Reemployed Annuitant information sheet.
• Payment of Permanent Change of Station (PCS) costs is not authorized, based on a determination that a PCS move is not in the Government interest.