This announcement is open to US Citizens, Veteran's preference will be applied.
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.
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.
Monday - Friday, 8:00AM - 4:30PM
Functional Statement Title/#:
Medical Records Technician (Coder), GS-675-00
Job family (Series)
0675 Medical Records Technician
Coders, Health Information
Health Information Systems Technicians
Health Information Technicians
Medical Records And Health Information Technicians
Medical Records Specialists
Medical Records Technicians
Conditions 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
Candidates must meet both Basic Requirements, Creditable Experience and Grade Determination by the closing date of this announcement ,11/30/2018 .
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 (1) Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR, (2) Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records). OR (3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience: (a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.
English Language Proficiency. MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
(1) Knowledge of Current Medical Record Technology. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current health information or health record technology and/or cancer registry practice and may be paid or non-paid employment.
(2) Quality of Experience. Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be equivalent to the next lower grade level. Experience satisfying this requirement must be active practice, which is paid/non-paid employment as a MRT.
(3) Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time workweek. For example, a MRT would receive 1 week of full-time credit for each 2 weeks of half-time work.
Candidates possessing certification by the American Health Information Management Association (AHIMA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), or Certified Coding Associate (CCA) and/or the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) or Certified Professional Coder-Payer (CPC-P). Candidates possessing 2-3 years of inpatient and outpatient coding experience.
In addition to the Basic Requirements listed above, candidates must meet the following:
GS-8 MRT (Coder) Full Performance Level :
Experience- One year of experience equivalent to the next lower grade level. This experience should have provided the candidate with the ability to apply current coding classifications specialty care areas, communicate with clinical staff for specific coding and documentation issues, research and solve coding and documentation related issues, correct system or processing errors and ensuring all assigned work is complete.
In addition to experience, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;
2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and
3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.
Medical Record Technician Series- VA Handbook 5005/70 Part II Appendix G35.
May include but not limited to standing up to two hours per day, use of both hands, use of fingers, and sitting up to eight hours per day.
A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
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 .
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 .
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.
The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and salary at which the candidate will be placed. For internal selectees eligible for promotion, the board will determine grade and HR will determine step in accordance with policy.
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 clearance
Drug test required
To apply for this position, you must provide a complete Application Package which includes:
- Resume should include dates, details of tasks performed in positions, and applicable certifications or educational experience.
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, documentation to support Veterans Preference or ICTAP/CTAP documentation (for displaced Federal employees).
Civil Service Preference Letter
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.
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 .
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