Medical Records Technician (Coder Inpatient/Outpatient)
DutiesThis position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program.
You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment.
Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application.
Assigns codes to documented patient care encounters (inpatients and outpatient) covering the full range of health care services provided by NF/SG VHS.
Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Selects and assigns codes from the current version of several coding systems to include the International Classification of Disease-Clinical modification and Procedure classification system (ICD-9-CM, ICD-10 CM, AND ICD-10 PCS), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by NF/SG VHS.
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.
Provides technical support in the areas of regulation and policy, coding requirements, resident supervision, reimbursement, workload accepted nomenclature, and proper sequencing.
Ensures provider documentation is complete and supports the diagnosis and procedure coded.
Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
Reports incorrect documentation or codes in the electronic patient record.
Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established time lines.
Works within a team environment; supports peers in meeting goals and deadlines.
Maintains a record of work accomplishments and backlogs providing a daily report to the coding manager.
Work Schedule:
Monday - Friday 8:
00 am - 4:
30 pm Virtual:
This is not a virtual position.
Relocation/Recruitment Incentives:
Not Authorized EDRP Authorized:
Authorized VISN8CCoE@va.
gov , the EDRP Coordinator for questions/assistance Permanent Change of Station (PCS):
Not Authorized Financial Disclosure Report:
Not required RequirementsConditions 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.
Must pass pre-employment physical examination.
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
QualificationsBASIC REQUIREMENTSUnited States Citizenship.
Citizen of the United States.
(Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.
)English Language Proficiency.
MRTs must be proficient in spoken and written English as required by 38 U.
S.
C.
7402(d), and 7407(d)Experience and EducationExperience.
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 complete;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.
(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.
Apprentice/Associate Level Certification through AHIMA or AAPC.
GRADE DETERMINATIONS:
In addition to the basic requirements for employment, the following must be metMRT Coder (Outpatient and Inpatient), GS-4A.
Experience or Education.
None beyond basic requirementsMRT Coder (Outpatient and Inpatient), GS-5A.
Experience.
One year of creditable experience equivalent to the next lower grade levelOR,B.
Education.
Successful completion of a 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;C.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)MRT Coder (Outpatient and Inpatient), GS-6A.
Experience.
One year of creditable experience equivalent to the next lower grade level.
B.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)MRT Coder (Outpatient and Inpatient), GS-7A.
Experience.
One year of creditable experience equivalent to the next lower grade level.
B.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)MRT Coder (Outpatient and Inpatient), GS-8A.
Experience.
One year of creditable experience equivalent to the next lower grade level.
B.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)References:
VA Handbook 5005/122, Part II, Appendix G57.
The full performance level of this vacancy is GS-8.
Preferred
Experience:
Must have at least 1 year of inpatient coding experience and 1 year of outpatient coding experience.
(1 full year, not a combination of time to equal 1 year.
)Physical Requirements:
The work is performed in an office setting which adequately lighted, heated and ventilated.
The physical demands of the work are generally minor.
The work is primarily sedentary (6-8 hrs.
) although, there is some walking (1 hr.
), bending (1 hr), and carrying of bulky files (1- 10 lbs.
) and some extended periods of standing (2 hrs.
).
EducationIMPORTANT:
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 informationThis 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 or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
Pursuant to VHA Directive 1193.
01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.
e.
, medical, religious or pregnancy).
VHA HCPs do not include remote workers who only infrequently enter VHA locations.
If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date.
The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment.
Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application.
Assigns codes to documented patient care encounters (inpatients and outpatient) covering the full range of health care services provided by NF/SG VHS.
Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Selects and assigns codes from the current version of several coding systems to include the International Classification of Disease-Clinical modification and Procedure classification system (ICD-9-CM, ICD-10 CM, AND ICD-10 PCS), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by NF/SG VHS.
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.
Provides technical support in the areas of regulation and policy, coding requirements, resident supervision, reimbursement, workload accepted nomenclature, and proper sequencing.
Ensures provider documentation is complete and supports the diagnosis and procedure coded.
Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
Reports incorrect documentation or codes in the electronic patient record.
Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database.
Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established time lines.
Works within a team environment; supports peers in meeting goals and deadlines.
Maintains a record of work accomplishments and backlogs providing a daily report to the coding manager.
Work Schedule:
Monday - Friday 8:
00 am - 4:
30 pm Virtual:
This is not a virtual position.
Relocation/Recruitment Incentives:
Not Authorized EDRP Authorized:
Authorized VISN8CCoE@va.
gov , the EDRP Coordinator for questions/assistance Permanent Change of Station (PCS):
Not Authorized Financial Disclosure Report:
Not required RequirementsConditions 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.
Must pass pre-employment physical examination.
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
QualificationsBASIC REQUIREMENTSUnited States Citizenship.
Citizen of the United States.
(Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.
)English Language Proficiency.
MRTs must be proficient in spoken and written English as required by 38 U.
S.
C.
7402(d), and 7407(d)Experience and EducationExperience.
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 complete;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.
(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.
Apprentice/Associate Level Certification through AHIMA or AAPC.
GRADE DETERMINATIONS:
In addition to the basic requirements for employment, the following must be metMRT Coder (Outpatient and Inpatient), GS-4A.
Experience or Education.
None beyond basic requirementsMRT Coder (Outpatient and Inpatient), GS-5A.
Experience.
One year of creditable experience equivalent to the next lower grade levelOR,B.
Education.
Successful completion of a 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;C.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)MRT Coder (Outpatient and Inpatient), GS-6A.
Experience.
One year of creditable experience equivalent to the next lower grade level.
B.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)MRT Coder (Outpatient and Inpatient), GS-7A.
Experience.
One year of creditable experience equivalent to the next lower grade level.
B.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)MRT Coder (Outpatient and Inpatient), GS-8A.
Experience.
One year of creditable experience equivalent to the next lower grade level.
B.
Demonstrated Knowledge, Skills, and Abilities for this Grade level.
.
(For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below)References:
VA Handbook 5005/122, Part II, Appendix G57.
The full performance level of this vacancy is GS-8.
Preferred
Experience:
Must have at least 1 year of inpatient coding experience and 1 year of outpatient coding experience.
(1 full year, not a combination of time to equal 1 year.
)Physical Requirements:
The work is performed in an office setting which adequately lighted, heated and ventilated.
The physical demands of the work are generally minor.
The work is primarily sedentary (6-8 hrs.
) although, there is some walking (1 hr.
), bending (1 hr), and carrying of bulky files (1- 10 lbs.
) and some extended periods of standing (2 hrs.
).
EducationIMPORTANT:
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 informationThis 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 or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
Pursuant to VHA Directive 1193.
01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.
e.
, medical, religious or pregnancy).
VHA HCPs do not include remote workers who only infrequently enter VHA locations.
If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date.
The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
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