Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below. This job is open to current permanent Department of Veteran Affairs employees, current permanent Federal employees of other agencies and all US Citizens. See "How You Will Be Evaluated" section for additional information.

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Duties of the Medical Records Technician (Coder) Auditor include but are not limited to:

• Performs weekly or monthly audits of outpatient encounters. Reviews results of external audits and prepares education and/or audit responses.
• Performs monthly audits related to VHA Directives to include in-house and contract coding audits, EPRP reviews, revenue related/CPAC audits and other coding risk areas identified by Compliance, CPAC, VISN, external auditors medical center leadership and HIMs.
• Researches current guidelines related to inpatient and outpatient services and provides guidance to coding department and clinical staff accordingly.
• Participates in committees/work groups to provide input as a coding expert related to coding services and identify risk areas to improve clinical documentation and coding accuracy.
• Produces audit reports, graphs, presentations, to track and trend coding errors and accuracy rates using quantitative and qualitative methods.
• Works with Lead Coder to identify training deficiencies and areas of Improvement. Provides feedback to coders to improve accuracy as requested. Provides feedback to providers, including education and training on coding guidelines and corrective measures. Ensures coding assignment and documentation follows VHA Coding guidelines, Joint Commission on Accreditation of healthcare organization (JCAHO0), ICD-10, CPT/AMA coding conventions, and payer guidelines for optimal reimbursement. Thoroughly reviews the patient's record to ensure that all conditions of care, operations, and procedures ore properly documented by the clinician and sequenced in order of importance.
• Audits new providers as they are newly employed.
• Interprets and applies knowledge of clinical classification systems such as International Classification of Disease (ICD), Current Procedural Technology (CPT), Systematized Nomenclature of Medicine (SNOMED), Healthcare Common Procedure Coding System (HCPCS) and health information systems.
• Determines and evaluates for compliance with the standards of regulatory and accrediting bodies such as Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Centers for Medicare and Medicaid Services etc.
• Provide technical advice and/or oversight on health information issues, privacy and coding compliance. This includes skill in interpreting and adapting health information management guidelines that are not completely applicable to the work or have gaps in specificity.
• Extracts information to generate reports from various databases (e.g. clinical, financial), and analyze data including a consideration of such issues as applicability, validity, reliability and the quality and characteristics of the data source etc.
• Produce various reports, graphs and PowerPoint presentations in various formats, presenting data to various organizational levels and providing technical education to medical staff.
• Reviews, audits, monitor and complete other assignments in specified time frames.

Work Schedule: Monday - Friday 7:00am - 3:30pm or 8:00am - 4:30pm
Telework: This position is currently authorized for telework - Location negotiable, but incumbent must live within a 50 mile radius of a VA Medical Center. to meet the Return to Office Executive Order requirement with the understanding that selected candidates may be required to Return to Office. This will be discussed during the interview process.
Remote: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.
Functional Statement #: 91545-A
Relocation/Recruitment Incentives: Not Authorized
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.
• 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

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.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Experience and/or Education:

• 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,
• 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,
• 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,

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:

• 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.
• 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).

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).

Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation.


Grade Determinations:
Experience: One year of creditable experience equivalent to the journey grade level GS-8 of a MRT (Coder). Creditable experience includes: 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. 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. 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. AND

Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have possess one of the following certifications:

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.

Employees at this level must have a Mastery Level Certification through AHIMA or AAPC. 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). AND

Demonstrated Knowledge, Skills, and Abilities
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.

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

The full performance level of this vacancy is GS-09.

Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation and would generally not require a pre-placement examination.

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.