Medical Records Technician (Coder) Job in Anywhere in the U.S. (remote job)

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

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.
• Have 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. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (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. Department of Education 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. The following educational/training substitutions are appropriate for combining education and creditable experience:(a)Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and 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 health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder) AND
• Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675series in VHA must have either (1), (2), or (3) below:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment.

GS-4 Grade Determination: Basic requirements indicated above.
GS-5 Grade Determination: Have one year of creditable experience equivalent to the next lower grade level (GS-04).

• Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).ii. Ability to navigate through and abstract pertinent information from health records.
• Knowledge of the ICD CM, 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 outpatient/ambulatory surgery records, based on health record documentation.
• Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines.

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.
GS-6 Grade Determination: Have one year of creditable experience equivalent to the next lower grade level (GS-05).

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation.
• Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
• Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)).iv. Ability to accurately apply the ICD CM, Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios.
• Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.

GS-7 Grade Determination: Have one year of creditable experience equivalent to the next lower grade level (GS-06).

• Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record.
• Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment.
• Ability to research and solve coding and documentation related issues.
• Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

GS-8 Grade Determination: Have one year of creditable experience equivalent to the next lower grade level (GS-07).

• Ability to analyze the health 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 health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

References: VA Handbook 5005, Part II, Appendix G57The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08.

Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds.

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer (TJO). Please visit the Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP), va.gov/EMPLOYEE/docs/The-Fair-Chance-to-Compete-Act.pdf for more information.

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

VISN 17 SSU USAS Group

Email

VISN17SSUUSAS@va.gov

Address

Audie L Murphy Memorial Veterans Hospital
7400 Merton Minter Boulevard
San Antonio, TX 78229
US