Clarification from the agency

Open to current permanent Department of Veteran Affairs employees, current permanent Federal employees of other agencies, and current/past/upcoming VHA Health Professions Trainee (HPT) Graduates. Veterans Preference is not applicable. NOTE: The 2-page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below.

Total Rewards of a Allied Health Professional

• Applies knowledge of medical record content, terminology, anatomy, physiology, disease processes, and official coding guidelines to assign basic and routine outpatient or inpatient professional service codes.
• Selects and assigns codes from current versions of ICD, CPT, and/or HCPCS.
• Learns to select diagnosis, operation, or procedure codes based on accepted coding practices, guidelines, conventions, and policies with instruction from a senior coder or supervisor.
• Reviews record documentation to abstract required medical, surgical, ancillary, demographic, social, and administrative data, developing an understanding of the organization and structure of an electronic patient record under guidance.
• Refers coding and documentation questions from providers to a senior coder or supervisor for resolution or guidance.
• Utilizes the facility's computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin; reviews identified data errors with a senior coder or supervisor and makes corrections as directed.
• Uses a variety of computer applications, including Outlook, Excel, Word, and Access, and develops proficiency with health record applications (VistA and CPRS) and the encoder product suite.
• Performs other duties as assigned depending on grade level.

Work Schedule: Full-time, Monday-Friday, 8:00am-4:30pm
Pay: Competitive salary and regular salary increases
Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year). Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Telework: This position is eligible for 100% Telework, with the understanding that selected candidates must reside within 50 miles of a VISN 19 facility. Although this position currently allows for 100% telework and are exempt from the return-to-office (RTO) policy, the position(s) may fall under the Presidential Memorandum titled "Return to In-Person Work" which will require you to go into the office if the exception is not approved when it is up for review.
Functional Statement #: 635-58044-A, 635-58045-A, 635-58046-A, 635-58047-A, 635-58048-A

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 dentification 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 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; 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,
  • 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.
• 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.
• Grandfathering Provision. 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 Level Requirements: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

Medical Records Technician (Coder-Outpatient), GS-4

1. Experience or Education. None beyond basic requirements.

Medical Records Technician (Coder-Outpatient), GS-5

1. Experience. One year of creditable experience equivalent to the next lower grade level; -OR-
2. Education. Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university.
3. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
   • Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and 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 accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation. v. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines.
   • Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, and the ability to follow-up on pending issues.

Medical Records Technician (Coder-Outpatient), GS-6

1. Experience. One year of creditable experience equivalent to the next lower grade level.
2. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
   • Ability to analyze the health record to identify all pertinent diagnoses and 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. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
   • Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)).
   • Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios. v. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.

Medical Records Technician (Coder-Outpatient), GS-7

1. Experience. One year of creditable experience equivalent to the next lower grade level.
2. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, 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 and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment.
   • Ability to research and solve coding and documentation related issues.
   • Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

Medical Records Technician (Coder-Outpatient), GS-8

1. Experience. One year of creditable experience equivalent to the next lower grade level.
2. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
   • 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 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 and 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.

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

Physical Requirements: In accordance with VA Handbook 5019 - Employee Occupational Health Service.

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.

Area of Consideration - Eligible applications will be reviewed and referred in the following order:

1. Current permanent VA employees of the facility.
2. All other VA employees.
3. Current permanent Federal employees of other agencies.

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

• Professional Certification
• 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)
• Clinical Applicant Resume/CV
• Performance Appraisal
• Professional Certification
• Resume
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript

Next steps