- Assigns codes to inpatient admissions; develops skill and knowledge of health record coding.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, to ensure ethical, accurate, and complete coding.
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
- Codes inpatient admission to obtain the most appropriate MS-DRG, including all MCCs, CCs, correct POAs to support VERA and 3rd party reimbursement.
- Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), and the Procedural Coding System (PCS).
- Selects diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
- Reviews health record documentation to abstract all required medical, surgical, demographic, social, and administrative data. Patient health records maybe paper or electronic.
- Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database.
- Operates a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access.
- Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance.
: Monday-Friday, 8am-4:30pm Telework
: Remote Virtual:
Remote Relocation/Recruitment Incentives
: Recruitment incentive may be offered to highly qualified applicant Financial Disclosure Report:
Not required RequirementsConditions 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.
- 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.
- 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.
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.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
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
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,
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,
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:
- 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)
. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC .Mastery Level Certification through AHIMA or AAPC 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.
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
: Medical Records Technician (Coder-Inpatient), GS-04Medical Records Technician, ( Inpatient), GS-4
(a) Experience or Education. None beyond basic requirements.Medical Records Technician ( Inpatient), GS-5
(a) Experience. One year of creditable experience equivalent to the next lower grade level;(b) Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.Medical Records Technician (Coder-Inpatient), GS-6
(a) Experience. One year of creditable experience equivalent to the next lower grade level.Medical Records Technician (Coder-Inpatient), GS-7
(a) Experience. One year of creditable experience equivalent to the next lower grade level.Demonstrated Knowledge, Skills, and Abilities.
In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
Ability to research and solve coding and documentation related issues.
Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.Medical Records Technician (Coder-Inpatient), GS-8
(a) Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities.
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 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.References:
VA Handbook 5005/12, Part II, Appendix G57
The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08.Physical Requirements:
Position is mostly sedentary, in an office type setting. Some light lifting ( under 15 lbs.), Light carrying ( under 15 lbs.), use of fingers to keyboard, and ability to read electronic health records on computer screen. EducationIMPORTANT:
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
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.
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 an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.