Duties
Duties include but not limited to:
- Code all inpatient stays (facility and professional fees), all write-in diagnoses and procedures for outpatient encounters and laboratory, radiology, surgical and outpatient encounters that are billed to insurance companies. Codes information from the medial records of patients to generate a clinical care patient care database for the Medical Center. Assures the maintenance and accuracy of the diagnostic and procedural statistics for the facility as well as optimum appropriate reimbursement from the third party payers, by the timely and accurate coding of diagnoses and procedures utilizing the required classification system.
- Captures data through the Ambulatory Care Data Capture Superbill Form (both printed and electronic), electronic visit notes, the Quadramed/DSS Complaint Coding Module (CCM) and the Patient Treatment File (PTF) in Vista and in Quadramed/DSS. Converts narrative electronic visit notes to ICD, CPT and HCPCS codes.
- Manually code from the medical record documentation and enter into the appropriate software packages. Inpatient data is captured by the Coders reading the electronic and paper medical record then converting the narrative to ICD, CPT and HCPCS codes.
- Validates data for accuracy of performance measurement, patient care, billing accuracy, reimbursement and research.
- Timely and accurate coding purpose of visit (diagnoses) including identifying the primary and secondary diagnoses to the most specific code available, services provided (procedures and/or Evaluation and Management level of care), practitioner, and other case mix data for all ambulatory and inpatient encounters.
- Maintains a control system to ensure comprehensive submission of all codes for the care provided into the Patient Care Encounter (PCE), Automated Information Capture System (AICS), Patient Treatment File (PTF), Appointment Management, Surgery Package and other applicable programs in VISTA. Use of judgment to adapt and interpret data to meet the data collection requirements accurately and within established time constraints. The ICD, CPT and HCPCS codes are updated bi-annually and annually and Medical Record Technicians must be knowledgeable in the changes. Comprehends both the physical process and the computer applications.
- Abstracting the diagnoses, procedures performed level of patient evaluation, drugs injected etc, for all inpatient stays. This information is converted into ICD, CPT and HCPCS codes and then entered into the appropriate VISTA software package via the Quadramed/DSS PTF module. This is accomplished by analyzing all hardcopy and electronic information that makes up each inpatient episode of care prepared in the normal course of business by a multidisciplinary team of healthcare providers.
- Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner. Ensures that all diagnoses and procedures that may impact the facility's reimbursement are identified and documented by the physician, sequenced correctly and coded in an accurate and ethical manner for optimum reimbursement. Determines correct codes for routine, and/or new and unusual diagnoses and procedures not clearly listed in ICD and CPT. Directly consults with physician for clarification of clinical data when encountering conflicting or ambiguous information.
- Assists physician, ancillary, administrative personnel and other clinical staff and ward clerks with concurrent documentation requirements in compliance with coding guidelines; retrieving patient health care data from various sources such as consolidated health records, Computerized Patient Record System (CPRS), diagnostic, therapeutic indices or clinical logs for research, planning, budgeting and marketing projects.
- Maybe required to train others on the Quadramed Compliant Coding Modules. Utilizes this system on an on-going basis to perform their core coding duties.
- Protects printed and electronic files containing sensitive data in accordance with the provisions of the Privacy Act of 1974 and other applicable laws, Federal regulations, VA statutes and policy, and VHA policy. Protects the data from unauthorized release or from loss, alteration, or unauthorized deletion. Follows applicable regulations and instructions regarding access to computerized files, release of access codes, etc.
Work Schedule: Monday to Friday, 7:30am - 4:00pm OR 8:00am - 4:30pm CST.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
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
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 / 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. OR,
- Education:
- (a) 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
- (b) 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. OR
- (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).
- Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
- (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
- (2) Mastery Level Certification through AHIMA or AAPC.
- (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
- English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
- Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
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: GS-8-Experience. In addition to meeting the basic requirements above, the following must be met:
- One year of creditable experience equivalent to the next lower grade level (GS-7). Experience should include: Inpatient MRTs (Coder) and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Review and record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder). 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. Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Use various computer applications to abstract records, assign codes, and record and transmit data. Ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
- And all of the following KSAs Knowledge, Skills, and Abilities must be demonstrated in your resume:
- Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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.
- Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
- 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:
- Certified through AHIMA or AAPC (CCS, CCS-P, RHIT, RHIA, CPC, COC, CIC)
- Inpatient and Outpatient Coding Experience
- Ability to abstract information from health records
Reference: VA Handbook 5005/122, PART II, APPENDIX G57, December 10, 2019The full performance level of this vacancy is GS-08.For more information on this qualification standard, please visit
https://www.va.gov/ohrm/QualificationStandards/.
The he full performance level of this vacancy is GS-08.
Physical Requirements: Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; use of computer screen; both hands required; ability to distinguish basic colors; hearing (aid permitted); sitting for up to 8 hours; repetitive motions for computer data entry ; ability to communicate with patients and staff.
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:
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 (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.
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 11/22/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12610888.
- 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.