Summary
The Oklahoma City VA Medical Center is currently recruiting for Medical Record Technicians (Coder-Inpatient) to work with the Health Administration Service. Medical Records Technicians (Coder) are skilled in classifying medical data from patient health records in the hospital setting and physician-based setting. These coding practitioners analyze and abstract patients health records and assign alpha-numeric codes for each diagnosis and procedure.
This job is open to
Clarification from the agency
This is an open continuous announcement open to current, permanent employees with the Veterans Health Administration. Qualified applicants will be considered and referred as vacancies become available.
Duties
The duties of the Medical Records Technicians (Coder-Inpatient) include the following, but are not limited to:
- Applies knowledge of medical record content, medical terminology, anatomy and physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine inpatient facility and/or professional services.
- Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding.
- Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
- Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database.
- Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the health record applications (VistA and CPRS) as well as the encoder product suite.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
- Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program.
- Maintains current knowledge of regulatory and policy requirements affecting coded information.
- Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data.
- Ensures provider documentation supports the diagnoses and procedures coded.
- Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
- Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays.
- Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
- Codes inpatient professional fee services for identified inpatient admissions.
- Establishes the primary and secondary diagnosis and procedure codes for inpatient professional services; links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided.
- Codes less complex inpatient surgical procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and 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 inpatient surgical cases.
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee.
- Reviews and codes assigned fee service Care in the Community inpatient encounters.
Work Schedule: Monday-Friday 8:00am-4:30pm
Telework: Not applicable.
Compressed/Flexible: Not Available
Virtual: This is a remote position.
Functional Statement #: 55039A, 55040A, 55041A, 55042, 55043A
Financial Disclosure Report: Not required
Requirements
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.
- You may be required to serve a probationary period.
- Subject to background/security investigation.
- Selected applicants will be required to complete an online onboarding process.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.
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.
- English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ยง 7403(f).
- Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3):
- Apprentice/Associate Level Certification through AHIMA or AAPC;
- Mastery Level Certification through AHIMA or AAPC;
- Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Experience: One (1) 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 (courses in medical terminology, anatomy & physiology, medical coding, & 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 & physiology, medical terminology, basic ICD diagnostic/procedural, & 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/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 & the health record, & 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 & 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, & health record techniques & procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
Grade Determinations for GS-4: Experience or Education. None beyond basic requirements.
Grade Determinations, GS-5: Experience: One (1) year of creditable experience equivalent to the next lower grade level;
OR
Education.Successful completion of four years of education above high school leading to 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.
Demonstrated KSAs. The candidate must demonstrate all of the following KSAs:
- Ability to use health information technology/software products used in MRT (Coder) positions (the electronic health record, coding, abstracting software, etc.).
- Ability to navigate through and abstract pertinent information from health records.
- Knowledge of the ICD CM, PCS 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 assign codes to outpatient/ambulatory surgery records, based on health record documentation.
- Knowledge of The Joint Commission requirements, Centers for Medicare/Medicaid Services (CMS), and/or health record documentation guidelines.
- Ability to manage priorities and coordinate work, in order to complete duties within required timeframes.
Grade Determinations GS-6: Experience. One year of creditable experience equivalent to the next lower grade level;
AND
Demonstrated KSAs. The candidate must demonstrate all of the following KSAs:
- Ability to analyze the health record to identify all pertinent diagnoses/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.
- Ability to apply laws and regulations on the confidentiality of health information (Privacy Act, Freedom of Information Act, and Health Insurance Portability & Accountability Act (HIPAA)).
- Ability to apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios.
- Knowledge of current classification systems, such as ICD CM, CPT, & HCPCS, and skill in applying said classifications to outpatient episodes of care and/or inpatient professional services based on health record documentation.
- Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).
Grade Determinations for GS-7: Experience. One year of creditable experience equivalent to the next lower grade level;
AND
Demonstrated KSAs. The candidate must demonstrate all of the following KSAs:
- 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/documentation issues, such as recording diagnoses & procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment.
- Ability to research/solve coding and documentation related issues.
- Skill in reviewing/correcting system or processing errors and ensuring all assigned work is complete.
- 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.
Grade Determinations GS-8: Experience. One (1) year of creditable experience equivalent to the next lower grade level;
AND
Demonstrated KSAs. The candidate must demonstrate all of the following KSAs:
- Ability to analyze the health record to identify all pertinent diagnoses/procedures for coding and to evaluate the adequacy of the documentation; 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/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.
References: VA Handbook 5005/122 PART II APPENDIX G57
Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.
Education
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
Benefits
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Review our benefits
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.
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.
Required Documents
To apply for this position, you must provide a complete Application Package which includes:
- Professional Certification
- Resume
- SF-50/ Notification of Personnel Action
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to 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)
- License
- Professional Certification
- Resume
- SF-15
- SF-50/ Notification of Personnel Action
- Transcript
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.
How to Apply
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 09/16/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12449361.
- To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
- Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
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