Medical Records Tech (Coder Outpatient)

at  US Veterans Health Administration

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.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 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) below:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• Experience and Education

(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).
Grade Determinations: Medical Records Technician (Coder- Outpatient) GS-8
Experience. One year of creditable experience equivalent to the next lower grade level.
Examples of this experience includes but not limited to: Performs coding on outpatient episodes of care and/or inpatient professional services. Selects and assign codes from current versions of ICD CM, CPT, and HCPCS classification systems. Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder). Reviews 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. Reviews provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. MRTs in this assignment also query clinical staff with documentation requirements to support the coding process. Uses various computer applications to abstract records, assign codes, and record and transmit data.

DEMONSTRATED KNOWLEDGE, SKILLS, AND ABILITIES. IN ADDITION TO THE EXPERIENCE ABOVE, THE CANDIDATE 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 findings, 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/or inpatient professional fee services coding.
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.
Assignment. Outpatient MRTs (Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation, and management services. They independently 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. They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties. They also directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. MRTs (Coder) must abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They also query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. MRTs (Coder) ensure audit findings have been corrected and refiled. They also use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

PREFERRED EXPERIENCE. OUTPATIENT CODING OF MULTIPLE SPECIALTIES (I.E. PRIMARY CARE, SURGICAL SPECIALTIES, MENTAL HEALTH, REHAB, MEDICAL SPECIALTIES).

References: See VA Handbook 5005, Part II, Appendix G57
The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is GS-8.
Physical Requirements: The work is primarily sedentary. Typically, the employee may sit comfortably to do the work. However, there may be some walking; standing; bending. No special physical demands are required to perform the work.

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/.

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.

• 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.

• Required Documents

As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have - whether you’re a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you’re eligible under their policies.

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

• Professional Certification
• Resume

IMPORTANT : You will not be contacted for additional information. Documents will not be accepted after the announcement has closed. Applicants will be deemed ineligible and removed from consideration, if your application package is incomplete and if supporting documentation is not submitted.

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)
• Other (1)
• Professional Certification
• Resume
• 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 03/05/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12328850.

• 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.

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.
Help

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)
• Other (1)
• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action
• Transcrip

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 03/05/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12328850.

• 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

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)
• Other (1)
• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action
• Transcrip