- Position Title
- Medical Records Technician (Coder-inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBSY-12717011-25-JH Opens in new window
- Open Period
- Wednesday, March 26, 2025 to Friday, April 4, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Are you currently employed by the Department of Veterans Affairs?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
2.
Are you an employee of the facility indicated for this position?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
Preferences
1.
Which of the following items describes your current or recent (within the last five years) political appointee service?
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
By submitting your application, you are certifying, to the best of your knowledge and belief, all the information submitted by you with your application for employment is true, complete, and made in good faith, and that you have truthfully and accurately represented your work experience, knowledge, skills, abilities and education (degrees, accomplishments, etc.). The information you provide as part of your application may be investigated. You are also certifying, and acknowledging, that misrepresenting your experience or education, or providing false or fraudulent information in, or with your application, may affect your eligibility for appointment and/or continued employment. False or fraudulent statements may be punishable by fine or imprisonment (18 U.S.C. 1001).
2.
In accordance with 38 U.S.C. 7402(d), No person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Are you proficient in basic written and spoken English?
If you are basing your qualifications on education (or a combination of education and experience) or if the position requires a college education to qualify, you must submit a copy of your transcripts with your application.
3.
Resume Reminder - Your resume must include the following information for each job listed:
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
Do you confirm that the above information is clearly stated for each work entry you are claiming experience for, and that each entry is full time unless otherwise annotated with part-time hours?
- Name and Contact Information
- Job title
- Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2019 to April 2021)
- Full-time or part-time status (include hours worked per week if part-time)
- Series and Grade, if applicable, for all Federal positions you have held.
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
Do you confirm that the above information is clearly stated for each work entry you are claiming experience for, and that each entry is full time unless otherwise annotated with part-time hours?
If applying as an internal or status candidate with current or former Federal Service, you must provide a copy of your most recent non-award SF-50, "Notification of Personnel Action", showing the highest grade or promotion potential held, dated within the last year.
All qualifying experience you possess must be clearly described in your application package. We will not make assumptions when reviewing applications. Failure to demonstrate your experience and knowledge, skills, and abilities (KSAs) in your application may result in disqualification. It is strongly recommended that you write to each KSA to demonstrate how you have gained each one in your application package or on a supplemental document. Please see the announcement for KSA requirements.
Assessment 1
Select “Yes” or “No” to the following question(s).
1.
Experience and Education: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), (3) or (4) below:
Do you meet the basic experience and education requirements for this occupation?
- 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: (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).
Do you meet the basic experience and education requirements for this occupation?
2.
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
Do you meet the basic certification requirement for this occupation? A copy of your certification is required with your application.
- Apprentice/Associate Level Certification through AHIMA or AAPC.
- Mastery Level Certification through AHIMA or AAPC.
- Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Do you meet the basic certification requirement for this occupation? A copy of your certification is required with your application.
3.
GS-4 Requirements:
(a) Experience or Education. None beyond basic requirements.
Does your resume demonstrate that you meet the education and/or experience and certification requirement as described above for appointment at the Grade of GS-4?
(a) Experience or Education. None beyond basic requirements.
Does your resume demonstrate that you meet the education and/or experience and certification requirement as described above for appointment at the Grade of GS-4?
4.
GS-5 Requirements
(a) Experience. One year of creditable experience equivalent to the next lower (GS-4) grade level; OR
(b) Education. Completion of a bachelor's degree from an accredited college or university recognized by the U.S. Dept. 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.
(c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-5?
(a) Experience. One year of creditable experience equivalent to the next lower (GS-4) grade level; OR
(b) Education. Completion of a bachelor's degree from an accredited college or university recognized by the U.S. Dept. 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.
(c) 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 and PCS Official Conventions and Guidelines for Coding and Reporting.
- Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation. 12.
- 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
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-5?
5.
GS-6 Requirements:
(a) Experience. One year of creditable experience equivalent to the next lower (GS-5) grade level.
(b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-6?
(a) Experience. One year of creditable experience equivalent to the next lower (GS-5) grade level.
(b) 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 and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
- Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation.
- Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-6?
6.
GS-7 Requirements:
(a) Experience. One year of creditable experience equivalent to the next lower (GS-6) grade level.
(b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-7?
(a) Experience. One year of creditable experience equivalent to the next lower (GS-6) grade level.
(b) 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 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 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.
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-7?
7.
GS-8 Requirements:
(a) Experience. One year of creditable experience equivalent to the next lower (GS-7) grade level.
(b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-8?
(a) Experience. One year of creditable experience equivalent to the next lower (GS-7) grade level.
(b) 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 inpatient 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 inpatient 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.
Does your resume demonstrate that you meet the experience and KSAs as described in the paragraph above for appointment at the Grade of GS-8?