Medical Records Technician (Coder) Auditor- (Outpatient and Inpatient)

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

Announcement will close once 25 applicants is reached

Major duties include, but are not limited to:

• Applies comprehensive 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.
• Reviews assigned codes from the current version of several coding systems to include current versions of ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines and conventions when validating the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Applies guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
• Reviews, analyzes and reports performance monitors for inpatient, outpatient, VERA and Non-VA Medical Care (purchased care) coding.
• Audits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records. Audits accuracy and completeness of assigned of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment.
• As a technical expert in health information coding matters, provides advice and guidance on documentation and coding requirements. Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines, audit standards, and results in appropriate data capture and reimbursement.
• Analyzes audit results and prepares summary feedback for individual coders and/or clinicians, making recommendations for improvement. Provides coding consultation to coders and/or clinicians related to coding and documentation questions.
• Performs other duties as assigned.

Work Schedule: Monday - Friday, 8:00 to 4:30 pm
Telework: Ad-Hoc only
Virtual: This is not a virtual position.
Functional Statement #: N/A
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

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 identification 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

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.

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. 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

Education 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. Dept. 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:

• 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.
• 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.

Certification: 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.

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).

Grade Determinations:
Medical Records Technician (Coder) Auditor, GS-9

Experience. One (1) year of creditable experience equivalent to the journey grade (GS-8) level of a MRT (Coder). This experience would include performing the full scope of inpatient/outpatient coding duties. This includes selecting and assigning codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems. Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data.

Certification. Employees at this level must have a mastery level certification.

• Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

• Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).
• Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
• Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.
• Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
• Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

Preferred Experience: Experience 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 analyzing and abstracting patient health records and assigning alpha-numeric codes for each diagnosis and procedure; Expertise in international classification of diseases (ICD), current procedural terminology (CPT), and the healthcare common procedure coding system (HCPCS) coding guidelines.


Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is GS-9.

Physical Requirements: The position is sedentary with intense focus on digital screens and repetitive hand movements. Key physical demands include prolonged sitting (8+ hours), constant computer monitor viewing leading to eye strain, and repetitive typing, alongside occasional light lifting of coding manuals. Light Lifting: Occasional lifting of reference books, such as ICD-10 or CPT coding manuals, typically weighing less than 10-25 lbs.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

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.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

To apply for this position, you must provide a complete Application Package which includes:

• Resume

Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.

Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.



The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

• Cover Letter
• DD-214/ Statement of Service
• Disability Letter (Schedule A)
• Disability Letter (VA)
• License
• Other (1)
• PCS Orders
• Performance Appraisal
• Professional Certification
• Resume
• Separation Notice (RIF)
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.

Veterans' preference does not apply for internal or other current permanent Federal agency employees.

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