EHRM Medical Records Technician (Coder In/Out)

Job description

Summary This position is located in the Health Information Management (HIM) section at the Edward Hines Jr. VA Hospital.

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

These coding practitioners analyze and abstract patients' health records, and assign alpha numeric codes for each diagnosis and procedure.

Responsibilities MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

MRT (Coder) may also provide education related to coding and documentation.

Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC.

Has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.

Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.

Coding systems include current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), 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 (E/M) code to ensure ethical, accurate, and complete coding.

adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data.

Patient health records may be paper or electronic.

Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing.

Insures provider documentation supports the diagnoses and procedures coded.

To ensure accurate coding may directly consult with the professional staff when conflicting or ambiguous clinical documentation is encountered.

Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment.

Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.

Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

Researches references to resolve any questionable code errors; contacts supervisor when needed.

Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.

At the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs.

Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequent changing projects and deadlines.

Work Schedule: Monday-Friday 7:30am-4:00pm Telework: Ad-hoc telework eligibility may be authorized Virtual: This is not a virtual position Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job.

All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.

Applicants who refuse to be tested will be denied employment with VA.

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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).

Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.

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).

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 interest.

In 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.

Qualifications BASIC REQUIREMENTS: Citizenship.

United States Citizenship.

(Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g.) Experience and Education: Must meet one of the following:(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).

Certification: Persons hired or reassigned to the Supervisory MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC.

(2) Mastery Level Certification through AHIMA or AAPC.

(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

IN ADDITION TO MEETING THE BASIC REQUIREMENTS LISTED ABOVE, YOU MUST MEET THE SPECIALIZED EXPERIENCE AT THE GS-10 LEVEL TO QUALIFY FOR THIS POSITION.

GS-4 Grade Requirements: Experience or Education.

None beyond basic requirements.

GS-5 Grade Requirements: Experience: One year of creditable experience equivalent to the next lower grade level (GS-4).

OR, Education: Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university 7recognized 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.

AND, Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: 1.

Ability to use health information technology and 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 and Reporting, and CPT guidelines.

4.

Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation.

5.Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines.

GS-6 Grade Requirements: Experience: One year of creditable experience equivalent to the next lower grade level (GS-5).

AND KSAs: 1.

Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the 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, and support the assigned codes.

This includes the 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 the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)).

4.

Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios.

5.

Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.

GS-7 Grade Requirements: Experience: One year of creditable experience equivalent to the next lower grade level (GS-6).

AND, KSAs: 1.

Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record.

2.

Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment.

3.

Ability to research and solve coding and documentation related issues.

4.

Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

GS-8 Grade Requirements: Experience: One year of creditable experience equivalent to the next lower grade level (GS-7).

AND KSAs: 1.

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.

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 professional fee services coding.

3.

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.

Education The full performance level of this vacancy is 8.

The actual grade at which an applicant may be selected for this vacancy is in the range of 4 to 8.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

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/.

Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee.

Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

This credited service can be used in determining the rate at which they earn annual leave.

Such credit must be requested and approved prior to the appointment date and is not guaranteed.

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions.

Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.

This job opportunity announcement may be used to fill additional vacancies.

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.

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer.

For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.

Salary Ranges: GS 4 $ 40,298-$52,394 GS 5 $ 45,087-$58,607 GS 6 $50,259-$65,334 GS 7 $55,850-$72,609 GS 8 $61,851-$80,412

Required Skill Profession

Other General