Medical Records Technician (Coder Inpatient Or Outpatient)

DutiesSummary

This announcement is open and continuous. Candidates will be reviewed and referred as applicable periodically as positions are available. You will receive updates on your status via email.

The incumbent serves as a Medical Record Technician (Coder) in the Health Information Sections (HIMS) of the Business Operations Service (BOS) Service Line. The incumbent is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided.


Responsibilities



Major 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.
• Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-10-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), 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.
• Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
• Uses a variety of computer based applications in day to day activities and duties.
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the Veteran's Equitable Resource Allocation (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 inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program.
Work Schedule: Monday - Friday, 8:00AM - 4:30PM
Functional Statement Title/#: Medical Records Technician (Coder Inpatient and Outpatient), GS-675-4/5/6/7/8
Physical Requirements: Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices.
Qualification References: VA Handbook 5005/122, PART II, APPENDIX G57 dated December 10, 2019.
Travel Required

Not required

Supervisory status

No

Promotion Potential

8

• Job family (Series)

  0675 Medical Records Technician

  Similar jobs
  • Coders, Health Information
  • Health Information Coders
  • Health Information Systems Technicians
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  • Medical Records And Health Information Technicians
  • Medical Records Technicians

• Requirements

  RequirementsConditions of Employment
  • You must be a U.S. Citizen to apply for this job
  • Designated and/or random drug testing may be required
  • Selective Service Registration is required for males born after 12/31/1959
  • You may be required to serve a probationary period
  • Subject to a background/security investigation
  • Must be proficient in written and spoken English
  • Selected applicants will be required to complete an online onboarding process
  QualificationsTo qualify for this position, applicants must meet both basic requirements and grade determinations by the closing date of this announcement, 12/31/2021.
  
  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 or Education. Candidates must meet one of the following:(1) 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,(2) 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,(3) 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,(4) 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. (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 must have Apprentice/Associate Level Certification through AHIMA or AAPC for all grades.
  • English Language Proficiency. MRT employees must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).
  Grade Determinations: Your resume will be utilized to adjudicate responses. See Required Documents for more information.
  • GS-4 Level: Experience or Education. None beyond basic requirements.
  • GS-5 Level: Experience. One year of experience equivalent to the next lower grade (GS-4); OR, Education. 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- must demonstrate all the following Demonstrated Knowledge, Skills, and Abilities (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 time frames, and the ability to follow-up on pending issues.
  • GS-6 Level: Experience. One year of experience equivalent to the next lower grade (GS-5). -AND- 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 ICDCM, 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 Level: Experience. One year of experience equivalent to the next lower grade (GS-6). -AND- 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 Level: Experience. One year of experience equivalent to the next lower grade (GS-7). -AND- 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.
  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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

  Additional information

  Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.
  
  This job opportunity announcement may be used to fill additional vacancies.
  
  It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
  
  This position is in the Excepted Service and does not confer competitive status.
  
  VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
  
  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.
  
  If you are unable to apply online view the following link for information regarding an Alternate Application.
  
  You may be eligible to apply for the Education Debt Reduction Program. Please contact Human Resources at this medical center and speak with the Education Debt Reduction Program Coordinator for additional information. This occupation is designated as hard to recruit and is eligible for the Education Debt Reduction Program. You must apply within 4 months (120 days) from your appointment date. Please contact Human Resources to speak with the Education Debt Reduction Program Coordinator for additional information and to apply.

  
  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, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
  
  If applicants are interviewed for the position, performance based interview questions will be used. For additional information regarding performance-based interviews, please review the following website on the internet: http://www.va.gov/pbi in addition, candidates may be interviewed by a panel.
  
  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.
  

  Background checks and security clearanceSecurity clearance

  Other

  Drug test required

  No

  Position sensitivity and risk

  Non-sensitive (NS)/Low Risk

  Trust determination process

  Suitability/Fitness

• Required Documents

  Required Documents

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

  • Resume
  , Copy of AHIMA or AAPC Certification.
  
  Your resume must provide your full name, mailing address and day/evening phone numbers, highest federal civilian grade held; for each work experience, list job title (include series/grade if Federal Job), duties and accomplishments, employer's name/address, supervisor's name/phone number, starting and ending dates (month/year), hours per week and salary.
  
  VA Form 10-2850c Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search. (Required Upon Selection)
  
  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
  • Apprentice/Associate Level Certification through AHIMA or AAPC
  • Performance Appraisal
  • Professional Certification
  • Resume
  • 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 http://www.fedshirevets.gov/job/vetpref/index.aspx.
  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.

• Benefits

  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. Learn 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.

• The public

  U.S. citizens, nationals or those who owe allegiance to the U.S.

Area of Consideration: US Citizens