Duties

Summary

This position is located in the Health Information Management (HIM) Section of Health Administration Service (HAS) at the Central Virginia VA Health Care System (CVVHCS). The MRT (Coder) is 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.
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Responsibilities

Inpatient Coding Auditors must be able to perform all duties of a MRT (Coder). These coding professionals analyze and abstract patient 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). The MRT (Coder) may also provide education related to coding and documentation.

Duties include:

Serving as experts of current coding conventions and guidelines related to inpatient professional and facility coding. Perform prospective and retrospective coding audits and utilize results to identify documentation and coding inadequacies and re-educate clinical and coding staff based on audit results.

Independently plans, organizes and performs auditing with emphasis on data validation, analysis, and generation of reports. Assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all coded data is fully documented and supported. Maintain statistical databases to track the results and validate the Coding program.

Facilitating improved overall quality, completeness and accuracy of coded data. Provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. Identify patterns and variations in coding practices with regular reports to the medical staff and management.

Providing technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

Consulting with the clinical staff for clarification of conflicting or ambiguous clinical data; assists them with documentation required to completely and accurately reflect the patient care provided.

Work Schedule: 8am - 4:30pm
Financial Disclosure Report: Not required
Telework: Schedule/Tour negotiable upon satisfactory completion of MRT training.

Travel Required

Not required

Supervisory status
No

Promotion Potential
None

Requirements

Conditions of Employment

• You must be a U.S. Citizen to apply for this job
• Designated and/or random drug testing may be required
• Selective Service Registration is required for males born after 12/31/1959
• You may be required to serve a probationary period
• Subject to a background/security investigation
• Must be proficient in written and spoken English
• Selected applicants will be required to complete an online onboarding process

Qualifications

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.
• 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).
  c. 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.

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).

Preferred Experience: Possess expert knowledge of inpatient ICD-10-CM/PCS coding.

Grade Determinations: Medical Records Technician (Coder) Auditor, GS-9

Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder). Certification. Employees at this level must have a mastery level certification.
• Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data. They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. They assist facility staff with documentation requirements to completely and accurately reflect the patient care provided. They provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data. They use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. They perform prospective and retrospective coding audits and use results to identify documentation, coding inadequacies, and re-educate clinical and coding staff based on audit results. They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports. They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data. They ensure that all coded data is fully documented and supported. They maintain statistical database(s) to track the results and validate the program. They identify patterns and variations in coding practices with regular reports to the medical staff and management.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  i. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).
  ii. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  iii. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.
  iv. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
  v. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

References: VA Handbook 5005/122 PART II APPENDIX G57, December 10, 2019

The full performance level of this vacancy is GS 9.

Physical Requirements: This is primarily a sedentary position, but the work requires some walking, bending, stooping and carrying of light objects such as manuals, documents, etc.

Education

Mastery 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).

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

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. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. 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.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

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.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

If you are unable to apply online view the following link for information regarding an Alternate Application .

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

Background checks and security clearance

Security clearance
Other

Drug test required
No

Position sensitivity and risk
Non-sensitive (NS)/Low Risk

Trust determination process
Suitability/Fitness

Required Documents

To apply for this position, you must provide a complete Application Package which includes:

• Professional Certification
• Resume

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

• Cover Letter
• DD-214/ Statement of Service
• Disability Letter (VA)
• Other (1)
• Performance Appraisal
• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action
• Transcript

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx .

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education .

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.