Medical Records Technician (Coder In/Out)

Clarification from the agency

This announcement is for current, permanent, federal employees within VHA only. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

PLEASE NOTE: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S. Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements. Any selected candidate must live within 50 miles of a VA Medical Center.

Duties include but are not limited to the following:

• Provides subject matter expertise to Service Line Leaders, and medical center staff.
• Interprets and applies The Joint Commission standards, VA regulations and medico-legal requirements; current Federal Codes pertinent to medical records; Veterans Administration policy memoranda, directives and handbooks pertinent to health information management; ICD-CM coding principles and nomenclature and the MS-DRG system; CPT and E&M rules; medical and procedural terminology; anatomy and physiology, regulations governing confidentiality of medical records; release of information laws and statutes; records management; and any policies pertaining to VA medical records.
• Provides training for HIM, clinical and administrative staff on HIM topics.
• Performs quality improvement projects regarding HIM issues.
• Assists the CHIM or designee in preparing various presentations.
• Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff.
• Reviews, analyzes and reports HIM performance monitors.
• Advises Principal Investigators and other clinical staff relating to methodologies of retrieving health care data for specific studies.
• Performs data retrieval for special studies as needed.
• Participates in various VAMC, VISN and national committees requiring health information management subject matter expertise.
• Performs quantitative and qualitative reviews of health record documentation to ensure all patient care data entered in the electronic health record (EHR) is accurate, timely, and completed. Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Serves as a liaison in the implementation of automated clinical applications pertaining to the EHR.
• Participates in facility committees and subcommittees related to health information and provides technical advice when necessary.
• Participates in training related to VHA Healthcare Information Systems such as VistA, CPRS and other software packages as they relate to HIM job functions.
• Analyzes clinical and administrative processes related to information flow. Tests and verifies software packages prior to activation in production mode.
• Coordinates with software developers in the local testing of software.

Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level.

Work Schedule: Monday - Friday 8:00am to 4:30pm
Virtual: This is a virtual position
Functional Statement #: 00000

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

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 and Education:

1. Experience: One year (52 weeks) of creditable experience equivalent to the next lower grade level of GS07.
2. Certification: Must have one of the following:
   1. Apprentice/Associate Level Certification through AHIMA or AAPC. OR
   2. Mastery Level Certification through AHIMA or AAPC. OR
   3. Clinical Documentation Improvement Certification through AHIMA or ACDIS.
3. In addition to experience, candidate must demonstrate the following KSAs:

(1) 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 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 inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services;
(3) 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.

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-08. The actual grade at which an applicant may be selected for this vacancy is GS-08.

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.
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Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment.

Physical Requirements: The work is primarily sedentary. Office setting is adequately heated, lighted and ventilated as well as meeting rooms and classrooms. Position may require occasional travel. Work environment involves everyday risks or discomforts which require normal safety precautions. Typically, the employee sits comfortably to do the work. However, there is usually some walking, standing, bending, and carrying of light items such as papers, books, files, etc. No special physical demands are required to perform the work

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
• SF-50/ Notification of Personnel Action

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 (VA)
• Performance Appraisal
• Resume
• 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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