Medical Records Technician (Coder - Inpatient / Outpatient)

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.

01Basic 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. MSAs must be proficient in spoken and written English in accordance with VA Handbook 5005, Part II, Chapter 3, Section A, paragraph 3.

AND: Experience and Education-Documentation Submitted 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, 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 completed; OR, 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: 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.

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). Please select the proper response for your experience and/or education. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). GRADE DETERMINATION for MRT (Coder) Inpatient/Outpatient: GS-08 Experience. One year of creditable experience equivalent to the next lower grade level. AND; Demonstrated KSAs.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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.

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.

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. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-8.

02Physical Requirements

The work is primarily sedentary with long periods of sitting at a desk, working with computers daily. Some work may require walking in offices and similar areas for meetings. Work may also require walking and standing in conjunction with travel to and attendance at meetings and conferences away from the worksite. The work does not require any special physical effort.

THIS IS AN ON SITE POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION The Medical Records Technician (Coder - Inpatient / Outpatient) reviews, analyzes, and abstracts information from patient health records and assigns appropriate ICD, CPT, and HCPCS codes for a wide variety of medical, surgical, diagnostic, and professional services.

The position requires extensive knowledge of medical terminology, anatomy and physiology, disease processes, coding guidelines, and regulatory requirements. The coder works independently to ensure coding accuracy, resolve coding issues, query providers for clarification when documentation is incomplete or ambiguous, and maintain compliance with national coding standards and VA policies.

This position directly contributes to accurate patient records, quality healthcare data, workload reporting, reimbursement processes, utilization review, and organizational performance measures. Major Duties Review inpatient and outpatient health records to identify diagnoses, procedures, and services for coding assignment. Assign accurate ICD, CPT, and HCPCS codes in accordance with applicable coding guidelines and regulations. Analyze clinical documentation to ensure code selection is supported and compliant.

Abstract and enter coded data into automated health record and coding systems. Identify, interpret, and code complex medical and surgical conditions, treatments, and procedures. Query providers for clarification of incomplete, conflicting, or ambiguous documentation. Review provider documentation to ensure coding and reimbursement requirements are met. Resolve coding edits, discrepancies, and reimbursement-related issues. Maintain productivity and quality standards while meeting established workload deadlines.

Use VistA, CPRS, encoder software, and other coding applications to perform coding and abstraction duties. Assist clinical staff with coding and documentation guidance and requirements. Support healthcare data collection, reporting, research, compliance reviews, and organizational performance initiatives. Work Schedule: 8:00am - 4:30pm, Monday - Friday Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 40727F Relocation/Recruitment Incentives: Not Authorized