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This Position Is No Longer Available

Job Title:  Medical Records Technician (Coder)
Department:  Department Of Veterans Affairs
Agency:  Veterans Affairs, Veterans Health Administration
Job Announcement Number:  637-13-319-MC-942110

This position is closed and no longer accepting online applications through USAJOBS.

The contents of the announcement can still be viewed.
$34,907.00 to $55,844.00 / Per Year
Monday, August 12, 2013 to Wednesday, September 04, 2013
Full Time - Permanent
6 vacancies in the following location:
Asheville, NC United StatesView Map
United States Citizens


Vacancy Identification Number (VIN): 942110 

To fulfill President Lincoln's promise – "To care for him who shall have borne the battle, and for his widow, and his orphan" – by serving and honoring the men and women who are America's Veterans. 

How would you like to become a part of a team providing compassionate care to Veterans?


These vacancies are advertised at the range of GS-06 to GS-8 grades covered by the VA qualifications standard.  


As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries.


NOTE:  The full performance level of this vacancy is GS-8.  The actual grade at which an applicant may be selected for this vacancy is in the range of GS-6 to GS-8.  The Professional Standards Board (a peer-review group) will review the selected candidate’s education and experience and recommend the grade and step at which the candidate will be placed.  The salary is based on the grade and step approved for the selected candidate.

VA encourages persons with disabilities to apply.



  • U. S. Citizenship
  • English Language Proficiency required
  • Designated and-or Random Drug Testing required
  • Background and-or Security Investigation required
  • All required documents- Incomplete packages will be rated INELIGIBLE


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Please read vacancy announcement in its entirety.  Failure to submit a completed application packet will result in non consideration for the position.


You may check the status of your submitted required documents by using Application Manager.  If you're unable to upload your documents, please print the fax cover sheet located in the how to apply section and fax it to the fax number listed on the cover sheet.  The Human Resources office does not accept hard copy application packets.  You must apply on line or use the fax method.  Required documents are not accepted after the closing of the announcement.


A major component of this station’s funding is dependent on the timely, accurate and complete capture of required abstracted data from each inpatient and ambulatory care episode of treatment.  Assigns codes to documented patient care encounters (inpatient and 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 the International Classification of Diseases-Clinical Modification (ICD-9-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS.


Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) 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 record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient 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.


Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient record.


Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.


Utilizes the facility computer system and software applications to correctly 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. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.


Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the medical record applications (VistA and CPRS) as well as the code selection software (e.g., QuadraMed nCoder+ Suite). Ensures current versions of all software applications are loaded and functional after any updates or changes.  


Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic medical record.


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


Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnostic Related Group (DRG). Upon patient admission to the Nursing Home Care Unit, codes the admission diagnosis for use by unit staff.


Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VISN VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.


Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.


Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.


Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD-9-CM and CPT coding guidelines and selects proper codes using the QuadraMed nCoder+ software; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.


Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay admissions to reflect all patient conditions and care up to the census date or to the requested billing date.


Reviews and codes assigned Fee Service patient encounters (inpatient and outpatient) using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.


Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.  Performs other related duties as assigned.


Relocation expenses are not authorized for this position.


PCS expenses are not authorized for this position.



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Citizenship.  Citizen of the United States.  (Non-citizens may be appointed when it is not possible to recruit qualified candidates in accordance with chapter 3, section A, paragraph 3g, this part.)


      b.  Experience and Education


      (1)  Experience.  Two years of experience that demonstrates the applicant’s ability to perform the work, or provides familiarity with the work.  Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT work.




      (2)  Education.  Successful completion of an associate’s degree with a major field of study in medical record technology/health information technology which was accredited by the American Health Information Management Association (AHIMA) at the time the program was completed.




      (3)  Experience/Education Combination.  Equivalent combinations of experience and education are qualifying.  The following educational/training substitutions are appropriate in this provision for combining education and experience:


      (a)  Successful completion of an associate’s degree in a field of study other than medical records/health information will substitute for 18 months of the required experience.


      (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 1 year of experience.


      (c)  Successful completion of a post-high school course of study in medical record technology, which includes courses in anatomy, physiology, and medical record techniques and procedures, may substitute on a month-for-month basis for up to 1 year of experience.

      (d)  Successful completion of post-high school courses for medical administrative personnel, obtained in a closely supervised training program given by the Armed Forces, may be substituted for experience on a month-for-month basis for up to 6 months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures.






      (a)  Experience.  One year of experience comparable to the next lower level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:


      (b)  Demonstrated Knowledge, Skills and Abilities


      1.  Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record;


      2.  Ability to navigate efficiently through the paper and electronic medical record to find needed information;


      3.  Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and ability to use judgment in completing assignments with incomplete or inadequate guidelines;


      4.  If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs.  This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable; 


      5.  Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA);


      6.  If assigned to a tumor registry position, ability to apply guidelines and standards for the maintenance of an approved tumor registry; and


      7.  If assigned to a medical coding position, comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), and skill in applying coding knowledge.



      (a)  Experience.  One year of experience comparable to the next lower grade level and must fully meet the KSAs at that level including those for tumor registry or coder assignments if applicable.  In addition, the candidate must demonstrate the following KSAs:


      (b)  Assignments.  Employees at this level will be assigned to a specific area of medical record/health information (tumor registry, medical coding, or medical records).  They may be in lead or supervisory positions, as appropriate to the assignment.  Core competencies are described for each type of assignment as follows.



   2. Medical Record Technician Coding Positions. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/ health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level. Since coding rules are specific to individual classification systems, knowledge of coding systems other than the one utilized in the position for which the individual is being boarded does not automatically meet the requirements of the position. Generally, to receive credit for experience, the coder should have performed the type of coding specified as a significant portion of duties on a regular and recurring basis, and provide evidence of the core competencies identified.


      a.  Demonstrated Knowledge, Skills and Abilities 


      (1) Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying coding knowledge to a wide range of specialty areas;


      (2) Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements;


      (3) Ability to communicate with clinical staff on coding and documentation issues such as recording inpatient and outpatient diagnoses and procedures, the use of encounter forms, the correct sequencing of diagnoses/ procedures, and/or the relationship between health care documentation and code assignment;


      (4) Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and


      (5) Skill in reviewing and correcting system or processing errors, reviewing transmission reports, and ensuring all assigned episodes are complete and accurate as appropriate to the duties assigned,




      (a)  Experience.  One year of experience comparable to the next lower grade level for the appropriate assignment area and must fully meet the KSAs at that level. 


      (b)  Assignments.  Employees at this grade level will be assigned to a specific area of medical record/health information, e.g., tumor registry, medical coding, or medical records.  They may be in lead or supervisory positions, as appropriate to the assignment.  Core competencies for the different assignments are listed with the assignment.


    2. Medical Record Technician (Medical Coder) Positions. This is considered to be the full performance level for this assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:


   a. Demonstrated Knowledge, Skills, and Abilities


      (1) Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;


      (2) Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT; and


      (3) Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, diagnostic studies and procedures, outpatient encounters, and inpatient professional fees for a highly diversified range of specialties and subspecialties, such as orthopedics, neurosurgery, cardiology, gastroenterology, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.


VA Handbook 5005/23, Part II, Appendix G35, Medical Records Technician QUALIFICATION STANDARD, and OPM Group Coverage Qualification Standard for Professional and Scientific Positions at VA Handbook 5005 at



Physical Requirements:  The work frequently requires lifting, carrying, filing, and handling of medical records, forms and supplies. Requires sitting, standing, bending and traveling to a variety of locations within the medical center. Requires daily extended use of computer terminal for processing all phases of daily work.


APPLICANTS PLEASE NOTE:  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 (particularly positions with a positive education requirement.)  Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.  Applicants can verify accreditation at the following website: All education claimed by applicants will be verified by the appointing agency accordingly.  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.

Veterans' Preference:

When applying for Federal Jobs, eligible Veterans should claim preference on their application or résumé. Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must complete an SF 15, Application for 10-Point Veteran Preference. Veterans who are still in the service may be granted tentative preference on the basis of information contained in their applications, but they must produce a DD Form 214 or other proof prior to appointment to document entitlement to preference.  For more information on Veterans' Preference, please visit


Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.   You may also be evaluated based upon the question responses you provide during a structured interview. In responding to structured interview questions you should be sure to cite specific examples of experience, explain exactly what you did, and the outcome.


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Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, thrift savings plan, and participation in the Federal Employees Retirement System. In addition to traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life.  For more information please visit us at


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


This position is in the Excepted Service and does not confer competitive status. 


Receiving Service Credit for 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 employees 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.


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For additional assistance with the online application process, please view the video at the following link:


 To begin the process, click the Apply Online button at the right side of this screen to create an account or log in to your existing USAJOBS account. Follow the prompts to complete the occupational questionnaire. Please ensure you click the Submit My Answers button at the end of the process.

YOU MUST INCLUDE VA FORM 10-2850c IN YOUR APPLICATION PACKAGE TO BE CONSIDERED FOR THIS VACANCY.   You may upload the completed form to your USAJOBS or Application Manager account if you apply online.  Then you can use the uploaded form again and again when applying for future vacancies.  Please see this guide ( for more information on uploading and re-using the form in your applications.  Other required forms and documents can also be saved in your account and used the same way.  Applicants are urged to apply online; this process is much easier and faster.

Note: To return to a previously Saved or Incomplete application, just reapply through your account in USAJOBS.  Check your account ( to see the status of your application after applying, including any messages that may have been sent to you.

If you cannot apply online:

  1. Click the following link to view and print the occupational questionnaire: View Occupational Questionnaire.
  2. Print this 1203FX form to provide your response to the occupational questionnaire:
  3. Fax the completed 1203FX form along with all supporting documents to (478)757-3144.  Your 1203FX form must be placed on top of all materials being faxed and will serve as a cover page for your fax transmission.
  4. Keep a copy of your fax receipt in case verification is needed.

To fax supporting documents you are unable to upload:

  1. Complete this cover page using the following Vacancy ID: 942110.  You must use this fax cover sheet in order for your documents to be matched with your online application.
  2. Fax your documents to (478)757-3144.

The complete Application Package must be submitted by 11:59 PM (EST) on Wednesday, September 04, 2013.


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

1. Your Résumé 

2. VHA-10-2850c Allied Health Application (required),complete form, print/sign/date and upload with your supporting documents

3. OF-306, Declaration of Federal Employment (required),complete form, print/sign/date and upload with your supporting documents

4. A completed Occupational Questionnaire

5. Standard Form (SF-50), (required) If you a current/former federal employment, please submit your most recent SF-50, reflecting your current series, grade and step.  Please do not submit an award SF-50

6. DD-214 member 4 copy (required)


Applicants CANNOT be contacted for any required documents listed above. Applicants who submit INCOMPLETE APPLICATION PACKAGES will receive a rating of INELIGIBLE. Requests for reconsideration will not be considered for applicants who fail to submit a complete application package. We cannot be held responsible for incompatible software, erroneous fax transmissions, etc.


Mark Condra
Phone: (828)298-7911x3564
Agency Information:
VHA Asheville VAMC
Department of Veteran Affairs
1100 Tunnel Road
Asheville, NC


After we receive your complete application package (including any required documents), your qualifications will be reviewed to decide if you meet the basic requirements.  You will be notified when this decision is made.

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