Medical Records Technician (Coder-Outpatient and Inpatient)

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below. All qualified candidates encouraged to apply. Open to U.S. Citizens but non-citizens may be appointed when it is not possible to recruit qualified citizens.

Total Rewards of a Allied Health Professional

Major duties may include, but are not limited to:

• Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services.
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
• Assigns codes to documented patient care encounters (outpatient professional services); encounters are routine and less complex or for only one specialty or subspecialty. Selects and assigns codes from the current version of the International Classification of Diseases (ICD) Clinical Modification (CM), 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 (E/M) code to ensure ethical, accurate, and complete coding. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters. HCPCS codes are used per guidelines.
• Codes all Operating Room 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 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
Recruitment Incentive (Sign-on Bonus): Not Authorized
Permanent Change of Station (Relocation Assistance): Not Authorized
Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).
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: Available
Virtual: This is not a virtual position.
Functional Statement #: 62247F, 62242F, 62241F, 62182F, and 62181F
Permanent Change of Station (PCS): Not Authorized.

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.
English Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
Experience or Education: 1year 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 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; ~OR~ Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. Training program must have led to eligibility for coding certification/certification examination, and sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at time the program was completed;~OR~ Experience/Education Combination. Equivalent combinations of creditable experience & education are qualifying for meeting basic requirements. Following educational/training substitutions are appropriate for combining education and creditable experience:(a) 6months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and health record, and 1year above high school, with a minimum of 6 semester hours of health information technology courses.(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by Armed Forces or U.S. Maritime Service, under close medical & professional supervision, may be substituted on a month-for-month basis for up to 6months of experience provided training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 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.
Grade Determinations :MRT (Coder-Outpatient and Inpatient): GS-4 Experience or Education. None beyond basic requirements. GS-5 1year of creditable experience equivalent to next lower grade level; OR, (b) Education. Successful completion of 4years of education above high school leading to a bachelor's degree from an accredited college or university recognized by U.S. Dept 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. KSAs In addition to experience above, and 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 & Reporting, & CPT guidelines. iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient & 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 & coordinate work to complete duties within required timeframes, & ability to follow-up on pending issues. GS-6 1year of creditable experience equivalent to next lower grade level. KSAs In addition to experience above, must demonstrate all of following KSAs: i. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding and to evaluate adequacy of 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, & support assigned codes. This includes 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 confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). iv. Ability to accurately apply ICD CM, PCS Official Conventions and Guidelines for Coding & Reporting, & 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 & 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 1year of creditable experience equivalent to next lower grade level. KSAs. In addition to experience above, demonstrate all of following KSAs: i. Skill in applying current coding classifications to a variety of inpatient & outpatient specialty care areas to accurately reflect service and care provided based on documentation in health record. ii. Ability to communicate with clinical staff for specific coding & documentation issues, such as recording inpatient & outpatient diagnoses & procedures, correct sequencing of diagnoses and/or procedures, and relationship between health record documentation & code assignment. iii. Ability to research & solve coding & documentation related issues. iv. Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete. v. Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct MS-DRG. GS-8 1year of creditable experience equivalent to the next lower grade level. KSAs In addition to the experience above, demonstrate all of following KSAs: i. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding & to evaluate adequacy of documentation. This includes ability to read & understand content of health record, terminology, significance of comments, & disease process/pathophysiology of patient. ii. Ability to accurately perform full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, & outpatient encounters, & inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services. iii. Skill in interpreting & adapting health information guidelines that are not completely applicable to work, or have gaps in specificity, and 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/.

Current VHA employees in this occupation who meet the criteria may qualify under Grandfathering Provision described in VA Qualification Standards.

Full performance level of this vacancy is GS-08. Actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08.

Physical Requirements: See VA Handbook 5019.

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

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.

• DD-214/ Statement of Service
• Disability Letter (VA)
• Other (1)
• Professional Certification
• Resume
• Transcript

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