Clarification from the agency

Applicants will be considered based on the following areas of consideration: 1) CPS/CP; 2) XP; 3) TP; 4) SSP (Sole Survivorship Preference); 5) All other qualified US citizens. *See "How You Will Be Evaluated" for additional information.

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Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services. Coders directly consult with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record and may also be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). They will also enter and correct information that has been rejected, when necessary, as well as, correct any identified data errors or inconsistencies. The basic duties of the position are:

1. Assign codes to documented patient care encounters (inpatient) covering the full range of health care services provided by the VAMC.
2. 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.
3. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD).
4. 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.

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.
• 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.

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/or Education:
  • Experience: 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure & format of a health record; OR,
  • Education: Associate's degree from an accredited college or university recognized by the U.S. Department of Education w/ a major field of study in health information technology/health information management, or a related degree w/ a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy & physiology, medical coding, and introduction to health records); OR,
  • Education: Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 year or more that included courses in anatomy & 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 that qualify for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education & creditable experience: (a) 6 months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, and 1 year above high school, w/ 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 & professional supervision, may be substituted on a month-for-month basis for up to 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques & procedures. Also, requires 6 additional months of creditable experience that is paid/non-paid employment equivalent to an MRT (Coder).
• Certification: Applicants must have 1 of the following, current, unexpired certifications:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certifications through AHIMA or ACDIS.

• GS-08: One year of creditable experience equivalent to the next lower grade level. This experience may include but is not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. They review and record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder). Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Use various computer applications to abstract records, assign codes, and record and transmit data. Ensure audit findings have been corrected and refiled.
• Demonstrated KSA's. In addition to the experience above, must demonstrate all of the following:
  • Ability to analyze the health record to identify all pertinent diagnoses & procedures for coding & to evaluate the adequacy of documentation; includes the ability to read & understand the content of the health record, terminology, significance of the findings, and the disease process/pathophysiology of the patient.
  • Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies & procedures, and outpatient encounters, and/or inpatient professional fee services coding.
  • Skill in interpreting & 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.

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 resume must include the following information for each job listed:
Job Title & Duties (be as detailed as possible)
Month & Year of Start/End date (i.e. June 2007 to April 2008)
Indicate Full-time or Part-time status (include hours worked per week)
References, to include contact information

If your resume includes a photograph or other inappropriate material or content (Personally Identifiable Information (PII)), it will not be used, and you may not be considered for this vacancy.

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.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

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

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.

Preference veterans will receive first consideration and will be referred in the following order:

• CPS/CP: A veteran who served at any time and who has a compensable service-connected disability rating of at least 10 percent.
• XP: A veteran who served at any time and has a present service-connected disability or is receiving compensation, disability retirement benefits, or pension from the military or the Department of Veterans Affairs but does not qualify as a CP or CPS; or is a purple heart recipient.
• TP: 5-point preference based on eligible active duty service.
• SSP (Sole Survivorship Preference): Discharged from active duty from the armed forces, after August 29, 2008, by reason of a "sole survivorship discharge."
• All other qualified US Citizens.