Medical Records Technician - Coder In/Out

Clarification from the agency

This announcement is open to all U.S. Citizens NOTE: The 2-page Resume requirement does not apply to this position.

Duties include but are not limited to:

• Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.
• Patient encounters are often complicated and complex requiring extensive coding expertise.
• 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.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) 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.
• Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Ensures provider documentation is complete and supports the diagnoses and procedures coded.
• Reports incorrect documentation or codes in the electronic patient health record.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
• Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Monday - Friday, 8:00am - 4:30pm. Hours are flexible with various tours available.
Remote: Yes. Remote exempted positions are reviewed annually and do not imply permanent remote work status.
Functional Statement #: 53831-A, 53832-A, 53833-A, 53834-A, 53835-A,
Relocation/Recruitment Incentives: Not authorized
Permanent Change of Station (PCS): Not authorized
Financial Disclosure Report: Not required

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.
• Must pass pre-employment physical examination.
• 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 may be required to serve a 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.

Qualifications

Basic Requirements:

• English Language Proficiency: Per VA Handbook 5005, Part II, Chapter 3, Section A, Paragraph 3j: No person will be appointed under authority of 38 U.S.C., chapter 73 or 74, to serve in a direct patient-care capacity in VHA who is not proficient in written and spoken English.
• Experience and Education:
• 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.
• 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)
• 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.
• Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either below: Apprentice/Associate Level Certification through AHIMA or AAPC, Mastery Level Certification through AHIMA or AAPC, Clinical Documentation Improvement Certification through AHIMA or ACDIS

Preferred Experience

• 1 year VA HIMS Coding experience (inpatient, outpatient, and/or surgery).

Your resume will be scored based on the standard qualifications and the Preferred Experience will be used to score as well. The quality of the Preferred Experience displayed in your resume could factor into whether or not you are forwarded to the hiring manager for consideration.

Grade Determinations: In addition to the Basic Requirements listed above, to qualify for each applicable pay grade, candidates must meet the requirements listed below:

GS-4 Experience and/or Education: None needed beyond Basic Requirements.

GS-5 Experience and/or Education:

1. Experience. One year of creditable experience equivalent to the next lower grade level (GS-4) OR
2. 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

AND

In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Ability to use health information technology and various office 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.
iii. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines
iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
vi. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.

GS-6 Experience: One year of creditable experience equivalent to the next lower grade level (GS-5).
AND
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. ii. 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.
iii. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
iv. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
v. Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7 Experience: One year of creditable experience equivalent to the next lower grade level (GS-6)
AND
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
ii. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment. iii. Ability to research and solve coding and documentation related issues.
iv. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
v. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.

GS-8 Experience: One year of creditable experience equivalent to the next lower grade level (GS-7)
AND
In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. 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.
ii. 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.
iii. 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.

Preferred Experience:

• GS-05: One year of coding experience
• GS-06: Two years of coding experience
• GS-07: Three years of coding experience
• GS-08: Four years of coding experience
• All grades: Collaborative, adaptability, problem solving, integrity, analytical, technical competence, self sufficiency, attention to detail, and consistency

References: VA Handbook 5005 PART II APPENDIX G57, MEDICAL RECORDS TECHNICIAN (CODER) QUALIFICATION STANDARD GS-0675 Veterans Health Administration

The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

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.

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following Competencies for this position:

• Attention to Detail
• Customer Service
• Decision Making
• Flexibility
• Integrity/Honesty
• Interpersonal Skills
• Learning
• Reading Comprehension
• Reasoning
• Self-Management
• Stress Tolerance
• Teamwork

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.

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

• Long-form resume/Curriculum vitae (CV)
• Professional Certification

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
• Long-form resume/Curriculum vitae (CV)
• Other (1)
• Other (2)
• Other (3)
• Professional Certification
• SF-50/ Notification of Personnel Action
• Transcript

Job series 0675 is exempt from Veteran's Preference for FY 2026.

Next steps