Lead Medical Records Technician (Coder)

Wallops Island, Virginia
Feb 07, 2023
Feb 09, 2023
Full Time

The duties of the Lead Medical Records Technician (Coder) in the Business Office include but not limited to:
  • Assigns codes to documented patient care encounters (inpatient and/or outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. 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 current versions of the International Classification of Diseases (ICD), 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. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under 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.
  • Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
Lead Functions:
  • Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies. Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill and ability to perform the full range of routine and non-routine responsibilities required. Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture. Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines. Distributes and balance the workload among employees in accordance with established workflow or job specialization, assures timely accomplishment of the assigned workload.
  • Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources. Reviews compliance monitors with Supervisor and identifies training needs. Reviews, audits, trains, monitors and completes special assignments within specified time frames.
  • Identifies training needs of individuals based on productivity and accuracy reports, rejects from billing, and spot checks. Makes recommendations to supervisor concerning disciplinary actions due to insufficient performance and identifies continuing education needs.
  • Required to train others on the encoder product suite. Utilizes this system on an on-going basis to perform core coding duties and audits.
  • Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided. Has constant interaction with health care providers evaluating and communicating with the expectation on improving health record documentation which will result in improved patient care and improved revenue generation. Educates providers through feedback, email queries, or informal meetings. Participates in the orientation of House Staff from affiliated medical schools and other personnel as needed.
Work Schedule: Monday - Friday, 8:00am-4:30pm, or based on facility needs
Telework: Available
Virtual: This is not a virtual position.
Functional Statement #: 598-00279-F
Relocation/Recruitment Incentives: Not authorized
Permanent Change of Station (PCS): Not authorized
Financial Disclosure Report: Not required


Conditions 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).
  • Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.


Basic 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: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
  • Experience and Education:
    • (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 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.

Master Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), 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).

Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist(CCDS).
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 Determinations:
Lead Medical Records Technician (Coder), GS-9
Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder).
Certification. Employees at this level must have a mastery level certification.
Demonstrated Knowledge, Skills and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc.
ii. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
iii. Ability to effectively communicate, both orally and in writing, in order to meet program objectives.
iv. Knowledge of training methods and the ability to provide training to new coding staff.
v. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
vi. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff.

Preferred Experience:
  • Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work
  • Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff
  • Strong knowledge of physician coding rules and guidelines
  • Experience in multi-specialty physician coding is highly preferred
  • Computer skills to include Microsoft Office
  • Must have and maintain coding certification
  • Ability to educate and train others
  • Minimum of three to five years coding experience
  • Ability to interpret, analyze, and abstract data/documentation
  • Must have strong knowledge of ICD-10 CM, CPT, & HCPCS
References: VA Handbook 5005/122, Part II Appendix G57, Medical Records Technician (Coder) Qualification Standard. This can be found in the local Human Resources Office.

The actual grade at which an applicant may be selected for this vacancy is GS-9.

Physical Requirements: Light lifting (under 15 pounds), use of fingers, both hands required, both eyes required, ability to distinguish basic colors, ability to distinguish shades of colors, multiple posture for 8 hours a day. (See VA Directive and Handbook 5019, Employee Occupational Health Services).


IMPORTANT: 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 information

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.

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 .