- Position Title
- Medical Records Technician (CDIS-Outpatient/Inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBTF-12718622-25-PGM-ECHO Opens in new window
- Open Period
- Friday, April 4, 2025 to Tuesday, June 10, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Are you a Veterans Health Administration employee?
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.
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.
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.
Your resume must be submitted in English and include the following information for each job listed:
- Job title Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2007 to April 2008)
- Full-time or part-time status (include hours worked per week)
- Series and Grade, if applicable, for all Federal positions you have held
- Please be aware that your answers will be verified against information provided on your resume. Be sure that your resume clearly supports your responses to all of the questions by addressing your work experience in detail.
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).
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.
Assessment 1
Select “Yes” or “No” to the following question(s).
1.
Basic Requirement - Experience and Education.
Do you have one of the following:
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 have one of the following:
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).
2.
Basic Requirement - Certification.
Do you possess any of the three below certifications?
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(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.
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.
Do you possess any of the three below certifications?
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(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.
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.
3.
Please list your Certification(s) number(s), and the expiration date(s).
Select “Yes” or “No” to the following question(s).
4.
Basic Requirement - English Language Proficiency.
Are you proficient in spoken and written English?
Are you proficient in spoken and written English?
5.
Specialized Experience - GS-9 Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS) (Outpatient and Inpatient)
Do you have
Experience. One year of creditable experience equivalent to the journey grade level (GS 8) of a MRT (Coder-Outpatient and Inpatient);
MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently 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. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties.
Demonstrated Knowledge, Skills, and Abilities.
- 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 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/or 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, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
OR,
An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
OR,
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; NOTE: See the definitions section of this standard (paragraph 2g above) for a detailed definition of mastery level certification.
OR,
Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.
AND
In addition to the experience above, do you demonstrate all of the following KSAs:
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record.
- Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
- Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
- Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS).
- Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.
- Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
6.
Advanced Certification.
Do you possess either a mastery level certification or a Clinical Document Improvement Certification through AHIMA or AAPC.?
Do you possess either a mastery level certification or a Clinical Document Improvement Certification through AHIMA or AAPC.?
7.
Please list whether you possess a mastery level certification or a Clinical Document Improvement Certification and provide the certification number and expiration date.