Clarification from the agency

This announcement is open to all US Citizens. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

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*Complete all application requirements detailed in the "Required Documents" section of this announcement.*

Major Duties and Responsibilities:

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).

• Perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services.
• Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management services.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC.
• Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, with limited guidance from higher level MRTs (Coder).
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications and procedures.
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code.
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria 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.
• 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.
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• 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 (VistA and CPRS) as well as the encoder product suite.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs.
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks.

Work Schedule: Monday - Friday; 7:30 a.m. - 4:00 p.m.
Compressed/Flexible:Not Authorized.
Recruitment Incentive (Sign-on Bonus): Not Authorized
Permanent Change of Station (Relocation Assistance): Not Authorized.
Pay: Competitive salary and regular salary increases.
Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).
Telework: This position currently has a Return to Office (RTO) mid-term extension (180-days). Remote work is currently authorized; however, candidates may be subject to return to office in the event policy changes or the exemption is not extended.
Virtual: This is not a virtual position.
Functional Statement #: 58048-A.
Permanent Change of Station (PCS): Not Authorized.

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.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination / evaluation.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Qualifications

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.- 1 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 - Associate's degree from an accredited college or university recognized by the U.S. DOE 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).(Copy of transcripts is required when submitting application) OR
• Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 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. The sponsoring academic institution must have been accredited by a national U.S. DOE accreditor, or comparable international accrediting authority at the time the program was completed.(Copy of completed program showing required courses/classes) OR
• Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
  • 6 months of creditable experience that indicates knowledge of medical 4 terminology, general understanding of medical coding and the health record, and 1 year above high school, with a minimum of 6 semester hours of health information technology courses.
  • 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 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).(Copy of valid transcripts required when submitting application).

Certification.

• Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have one of the below:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Grade Determinations In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates:

GS-8 Medical Records Technician (Coder-Outpatient) Full Performance Level

• Experience.
  • 1 year of creditable experience equivalent to the next lower grade level.

GS- 8 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, 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 and procedures, and outpatient encounters, and inpatient professional fee services coding.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity.
• The ability to use judgment in completing assignments using incomplete or inadequate guidelines.

This vacancy is listed at the full performance level GS -8.

For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

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, resume, 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.

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.