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Medical Records Technician (Coder Inpatient and Outpatient)

Department of Veterans Affairs
Veterans Health Administration
This job announcement has closed

Summary

Vacancy Identification Number (VIN): 11225556.

Please read this announcement in its entirety before beginning the application process to ensure you submit all the required documents.

Preview the application before applying for basics qualification requirements, the experience / education and (KSAs) for each grade level for the MRT (Coder-Outpatient and Inpatient):
https://apply.usastaffing.gov/ViewQuestionnaire/11225556.

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Overview

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Hiring complete
Open & closing dates
09/07/2021 to 09/27/2021
Salary
$31,520 to - $62,894 per year
Pay scale & grade
GS 4 - 8
Locations
1 vacancy in the following locations:
Murfreesboro, TN
Location Negotiable After Selection, United States
Telework eligible
Yes—as determined by the agency policy.
Travel Required
Not required
Relocation expenses reimbursed
No
Appointment type
Permanent
Work schedule
Full-time
Service
Excepted
Promotion potential
8
Supervisory status
No
Security clearance
Not Required
Drug test
No
Announcement number
CBTG-13658-11225556-21-WLH
Control number
613323300

This job is open to

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Clarification from the agency

Current and permanent Department of VA employees only. 1st consideration to current and permanent TVHS employees. 2nd consideration to current and permanent VA Wide employees.

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Duties

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This job opportunity announcement (JOA) will be used to fill one (1) full-time and permanent Medical Records Technician (Coder-Outpatient and Inpatient) vacancy at the Murfreesboro, TN Veteran Affairs Medical Center (VAMC), with Business Office Service.

The position is located in the Health Information Management (HIM) section in the Business Office at the Tennessee Valley Healthcare System (TVHS). 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. The duties included but are not limited to:

  • Assigns codes to documented patient care encounters covering the full range of health care services provided by the medical center.
  • 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 code to ensure ethical, accurate, and complete coding.
  • 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 medical center.
  • Performs a comprehensive review of the patient health record (paper or electronic) to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
  • 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.
  • Ensures 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.
  • Corrects any identified data errors or inconsistencies in a timely manner.
  • Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.
  • 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 as well as the encoder product suite.
  • Orients and instructs new personnel and/or students.
  • Works within a team environment; to meet goals and deadlines; multiple tasks; works under pressure; and flexible

Work Schedule: Monday - Friday 7:30 a.m. - 4:00 p.m. CST
Telework: Available for highly qualified applicants one to two days a week with approve telework agreement.
Virtual Telework: Available for highly qualified applicants at the full performance GS-08 grade only. Work performed on a full-time basis using VA-leased space or at a VA facility other than the facility that hired the employee.
Remote Telework: Available for highly qualified applicants at the full performance GS-08 grade only. Work is performed on full-time basis anywhere other than a VA facility or using VA-leased space.
Position Title/Functional Statement #:Medical Records Technician (Coder Inpatient and Outpatient)/PD000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required.

Requirements

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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
  • 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
  • Participation in the seasonal influenza and Coronavirus Disease 2019 (COVID-19) Vaccination programs are requirements for all Department of Veterans Affairs Health Care Personnel (HCP)
  • Following initial certification, credentials must be maintained through rigorous continuing education.

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:
  • Physical Requirements.
  • Proficient in spoken and written English Language.
  • 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. (See the Education Section of this announcement for qualification based on education.);
    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. (See the Education Section of this announcement for qualification based on education.)
  • Certification. (See the Education Section of this announcement for additional information regarding certification) Persons hired or reassigned to MRT (Coder) positions in the GS-0675series 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.
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: In addition to the basic requirements, the below qualification requirement must be met at the grade(s) in which you are applying.

GS-04: None beyond the basic requirements.
GS-05: One year of creditable experience equivalent to the lower grade level or successful completed a bachelor's degree from an accredited school with a major filed of study in health information management, or a related degree with a minimum of 24 semester hours in health information management or technology and must demonstrate the KSAs for this grade:
  1. Ability to use health information technology and various office 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 inpatient and outpatient episodes of care based on health record documentation.
  5. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.vi. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.
GS-06: One year of creditable experience equivalent to the lower grade level and must demonstrate the KSAs for this grade:
  1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to 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 HIPAA).iv. Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
  4. Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.
GS-07: One year of creditable experience equivalent to the lower grade level and must demonstrate the KSAs for this grade:
  1. Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas 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 inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code 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.
  5. 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.
GS-08: One year of creditable experience equivalent to the lower grade level and must demonstrate the KSAs for this grade.
  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 comments, 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 inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  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.
References: VAHB 5005/122 Part II Appendix G57 dated 12/10/2019

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-07 to GS-08.

Education

Basic Requirements (Education):
(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).
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.

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. This is considered an entry level coding certification and is limited to certification obtained through the American Health Information Management Association (AHIMA), or the American Academy of Professional Coders (AAPC). To be acceptable for qualifications, the specific certification must represent a comprehensive competency in coding across a wide range of services. Stand-alone specialty certifications do not meet the definition of apprentice/associate level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of apprentice/associate level certification may be added/removed by the above certifying bodies. However, current apprentice/associate level certifications include: Certified Coding Associate (CCA), Certified Professional Coder-Apprentice (CPC-A) and Certified Outpatient Coding-Apprentice (COC-A).
  2. 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).
  3. Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Clinical 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).

Additional information

Physical Requirements: The work is primarily sedentary. There is walking, bending and reaching required such as for filing or locating material, and carrying items such as reports, documents, and supplies. Entering data and word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain. A portion of each day is spent in the laboratory, sorting and preparing samples for testing, which involves periods of standing.

Definitions:

  • (a.) Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder).
  • (b.) Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means.
  • (c.) Part-Time Experience. Part-time experience as a professional MRT is creditable according to its relationship to the full-time work week. For example, an MRT would receive one week of full-time credit for each two weeks of half-time work.
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 or need to fax a document you do not have in electronic form, 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.

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