Medical Record Technician (Coder-Outpatient and Inpatient)

• 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.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7 2025 drivers licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the Required Documents section of this announcement.

As a condition of employment for accepting this position you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public determining if your employment advances the public interest we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period your employment will be terminated unless you receive certification in writing that your continued employment advances the public interest.

Basic Requirements:
(a) United States Citizenship: Must be a U. S. citizen.
(b) English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English.
(c) Certification. MRT (Coder) GS-0675 must have either (1) (2) or (3) below:

(1) Apprentice/Associate Level Certification through AHIMA or AAPC.
Certified Coding Associate (CCA)
Certified Professional Coder-Apprentice (CPC-A)
Certified Outpatient Coding-Apprentice (COC-A)

(2) Mastery Level Certification through AHIMA or AAPC.
Certified Coding Specialist - Physician-based (CCS-P)
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Professional Coder (CPC)
Certified Outpatient Coder COC)
Certified Inpatient Coder (CIC)
Certified Coding Specialist (CCS)

(3) Clinical Documentation Improvement
Certification through AHIMA or ACDIS.
Clinical Documentation Improvement Practitioner (CDIP)
Certified Clinical Documentation Specialist

(1) Experience. One year of creditable experience that indicates knowledge of medical terminology anatomy physiology pathophysiology medical coding & the structure/format of a health record. OR
(2) Education. An associates degree from an accredited college/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 & physiology medical coding & introduction to health records).OR
(3) Completion of an AHIMA approved coding program /other intense coding training program of approximately one year or more that included courses in anatomy and physiology medical terminology basic ICD diagnostic/procedural & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination the sponsoring academic institution must be accredited by a national U.S. Department of Education accreditor/comparable international accrediting authority at the time the program was completed.

(4) Experience/Education Combination. Equivalent combinations of creditable experience/education are qualifying for meeting the basic requirements.(a) Six months of creditable experience that indicates knowledge of medical terminology general understanding of medical coding & the health record and one year above high school with a minimum of 6 semester hours..(b) Successful completion of a course for medical technicians hospital corpsmen medical service specialists/hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical professional supervision.

GRADE DETERMINATIONS AND ASSIGNMENTS.
(1) MRT (Coder-Outpatient and Inpatient): GS-4
Experience or Education. None beyond basic requirements.

(2) MRT (Coder-Outpatient and Inpatient): GS-5
(a) Experience 1 year of creditable experience equivalent to next lower grade level;
OR
(b) Education. Successful completion of 4years of education above high school leading to a bachelors degree from an accredited college or university.
Demonstrated Knowledge Skills and Abilities (KSAs). In addition to experience above and demonstrate all of the following KSAs:
1. 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.).
2. Ability to navigate through and abstract pertinent information from health records.
3. Knowledge of the ICD CM PCS Official Conventions and Guidelines for Coding & Reporting & CPT guidelines.
4. Ability to apply knowledge of medical terminology human anatomy/physiology & disease processes to accurately assign codes to inpatient & outpatient episodes of care based on health record documentation.
5. Knowledge of The Joint Commission requirements CMS and/or health record documentation guidelines.
6. Ability to manage priorities & coordinate work to complete duties within required timeframes & ability to follow-up on pending issues.

MRT (Coder-Outpatient and Inpatient): GS-6
(a) Experience 1 year of creditable experience equivalent to next lower grade level.
KSAs In addition to experience above must demonstrate all of following KSAs:
1. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding and to evaluate adequacy of documentation.
2. Ability to determine whether health records contain sufficient information for regulatory requirements are acceptable as legal documents are adequate for continuity of patient care & support assigned codes. This includes ability to take appropriate actions if health record contents are not complete accurate timely and/or reliable.
3. Ability to apply laws and regulations on confidentiality of health information (e.g. Privacy Act Freedom of Information Act and HIPAA).
4. Ability to accurately apply ICD CM PCS Official Conventions and Guidelines for Coding & Reporting & CPT Guidelines to various coding scenarios.
5. Comprehensive knowledge of current classification systems such as ICD CM PCS CPT HCPCS and skill in applying classifications to both inpatient & outpatient records based on health record documentation.
6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

GS-7 Experience 1 year of creditable experience equivalent to next lower grade level.
KSAs. In addition to experience above demonstrate all of following KSAs:
1. Skill in applying current coding classifications to a variety of inpatient & outpatient specialty care areas to accurately reflect service and care provided based on documentation in health record.
2. Ability to communicate with clinical staff for specific coding & documentation issues such as recording inpatient & outpatient diagnoses & procedures correct sequencing of diagnoses and/or procedures and relationship between health record documentation & code assignment.
3. Ability to research & solve coding & documentation related issues.
4. Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete.
5. Ability to abstract assign & sequence codes including complication or comorbidity/major complication or comorbidity (CC/MCC) & POA indicators to obtain correct MS-DRG.

GS-8 experience 1year of creditable experience equivalent to the next lower grade level.
KSAs In addition to the experience above demonstrate all of following KSAs:
i. Ability to analyze health record to identify all pertinent diagnoses & procedures for coding & to evaluate adequacy of documentation. This includes ability to read & understand content of health record terminology significance of comments & disease process/pathophysiology of patient.
ii. Ability to accurately perform full scope of outpatient coding including ambulatory surgical cases diagnostic studies and procedures & outpatient encounters & inpatient facility coding including inpatient discharges surgical cases diagnostic studies & procedures & inpatient professional services.
iii. Skill in interpreting & adapting health information guidelines that are not completely applicable to work or have gaps in specificity and ability to use judgment in completing assignments using incomplete or inadequate guidelines
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).

Reference: For more information on this qualification standard please visit actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to the full performance level of a GS-8.