MEDICAL RECORDS TECHNICIAN (CODER-Outpatient and Inpatient)

Duties The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers.
This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest.
As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran.
This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community.
This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.
Major Duties include but are not limited to: Assigns codes to documented patient care encounters (inpatient or outpatient) for one or more specialty and subspecialty health care services provided by the VAMC.
Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
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.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data.
Assists facility staff with basic documentation requirements to reflect the patient care provided.
Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment.
Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access.
Works within a team environment.
Identifies the principal diagnosis and principal procedure for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program.
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.
Codes Operating Room procedures reported in the Surgical Package of the VistA hospital system.
Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census.
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.
Work Schedule: 8:00am to 4:30pm Telework: Ad-hoc, situational can be discussed during interview.
Virtual: This is not a virtual position.
Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required Requirements 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 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 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).
Certification.
Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC.
Mastery Level Certification through AHIMA or AAPC.
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.
Loss of Credential.
Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers.
An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment.
At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.
English Language Proficiency.
MRTs (Coder) must be proficient in spoken and written English as required by 38 U.
S.
C.
§ 7403(f).
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: Please See Education Section for Grade Determinations.
References: VA Handbook 5005/122, Part II, Appendix G57 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-4 to GS-8.
Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position.
Questions about physical demands or environmental factors may be addressed at the time of evaluation or examination.
Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Grade Determinations: Medical Records Technician (Coder-Outpatient and Inpatient) GS-4: Basic Requirements.
GS-5: Experience.
One year of creditable experience equivalent to the next lower grade level (GS-4); OR Education.
Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
Demonstrated Knowledge, Skills, and Abilities.
In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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.
).
Ability to navigate through and abstract pertinent information from health records.
Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
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.
Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.
GS-6: Experience.
One year of creditable experience equivalent to the next lower grade level (GS-5).
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.
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.
Ability to apply laws and regulations on the confidentiality of health information (e.
g.
, Privacy Act, Freedom of Information Act, and HIPAA).
Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
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.
Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.
GS-7: Experience.
One year of creditable experience equivalent to the next lower grade level (GS-6).
Demonstrated Knowledge, Skills, and Abilities.
In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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.
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.
Ability to research and solve coding and documentation related issues.
Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
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-8: Experience.
One year of creditable experience equivalent to the next lower grade level (GS-7).
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, 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.
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: https://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: https://sites.
ed.
gov/international/recognition-of-foreign-qualifications/.
Additional information Receiving Service Credit or 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.
Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
This credited service can be used in determining the rate at which they earn annual leave.
Such credit must be requested and approved prior to the appointment date and is not guaranteed.
This job opportunity announcement may be used to fill additional vacancies.
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.
Pursuant to VHA Directive 1193.
01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.
e.
, medical, religious or pregnancy).
VHA HCPs do not include remote workers who only infrequently enter VHA locations.
If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date.
The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.
Benefits A career with the U.
S.
government provides employees with a comprehensive benefits package.
As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.
Opens in a new windowLearn more about federal benefits.
Review our benefits Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.
Contact the hiring agency for more information on the specific benefits offered.
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.
Benefits A career with the U.
S.
government provides employees with a comprehensive benefits package.
As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.
Opens in a new windowLearn more about federal benefits.
Review our benefits Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.
Contact the hiring agency for more information on the specific benefits offered.
Required Documents As a new or existing federal employee, you and your family may have access to a range of benefits.
Your benefits depend on the type of position you have - whether you're a permanent, part-time, temporary or an intermittent employee.
You may be eligible for the following benefits, however, check with your agency to make sure you're eligible under their policies.
To apply for this position, you must provide a complete Application Package which includes: Professional Certification Resume The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.
Cover Letter DD-214/ Statement of Service Disability Letter (VA) RECOMMENDED: Write to the Knowledge, Skills, and Abilities (KSAs) on a separate document - KSAs are found under qualification/grade requirements in the announcement.
VA Form 10-2850c (Signed within the past 12 months) Professional Certification Proof of Marriage Status Resume SF-15 SF-50/ Notification of Personnel Action Transcript Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire.
You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.
).
If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.
), and dates of impending separation.
Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form.
Documentation is required to award preference.
For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
If you are relying on your education to meet qualification requirements: 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.
Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.
S.
Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
How to Apply All applicants are encouraged to apply online.
To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below.
The complete application package must be submitted by 11:59 PM (ET) on 02/01/2024 to receive consideration.
To preview the questionnaire click https://apply.
usastaffing.
gov/ViewQuestionnaire/12277987.
To begin, click Apply Online to create a USAJOBS account or log in to your existing account.
Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.
usajobs.
gov/Account/Login, select the Application Status link and then select the more information link for this position.
The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application.
Your uploaded documents may take several hours to clear the virus scan process.
To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement.
You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
Agency contact information Jessica Echlin Phone 651-405-5661 Email Jessica.
Echlin@va.
gov Address Fargo VA Medical Center 2101 Elm Street Fargo, ND 58102 US Next steps Once your online application is submitted you will receive a confirmation notification by email.
After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.
After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email.
Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview.
All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications.
Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons.
Wearing a face mask is required when an exemption to the influenza vaccination has been granted.
HCP in violation of this directive may face disciplinary action up to and including removal from federal service.
HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties.
VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.
HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.
HPTs may be paid or unpaid and include residents, interns, fellows and students.
HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
Fair and Transparent The Federal hiring process is set up to be fair and transparent.
Please read the following guidance.
Equal Employment Opportunity (EEO) Policy Reasonable accommodation policy Financial suitability Selective Service New employee probationary period Signature and false statements Privacy Act Social security number request Required Documents To apply for this position, you must provide a complete Application Package which includes: Professional Certification Resume The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.
Cover Letter DD-214/ Statement of Service Disability Letter (VA) RECOMMENDED: Write to the Knowledge, Skills, and Abilities (KSAs) on a separate document - KSAs are found under qualification/grade requirements in the announcement.
VA Form 10-2850c (Signed within the past 12 months) Professional Certification Proof of Marriage Status Resume SF-15 SF-50/ Notification of Personnel Action Transcript Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire.
You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.
).
If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.
), and dates of impending separation.
Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form.
Documentation is required to award preference.
For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
If you are relying on your education to meet qualification requirements: 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.
Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.
S.
Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
Help This job is open to The public U.
S.
Citizens, Nationals or those who owe allegiance to the U.
S.
Clarification from the agency This announcement is open to the public and employees of other Federal agencies.
Current, permanent VA employees should apply to announcement CBSY-12277986-24-JE.