- Position Title
- Medical Records Technician (Coder Outpatient & Inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBTF-12721130-25-PGM-ECHO Opens in new window
- Open Period
- Friday, April 4, 2025 to Friday, April 18, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Do you claim Veterans’ Preference?
2.
Are you a current permanent Federal employee from an agency other than Department of Veterans Affairs?
To verify your eligibility, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50) or equivalent personnel action form.
To verify your eligibility, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50) or equivalent personnel action form.
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).
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?
In order to receive appropriate consideration, you should submit proper documentation if you are claiming eligibility for Veterans' Preference, which includes a copy of your DD-214 (member copy 4 or earlier version that shows character of service). Applicant's claiming 10-Point preference should also submit an SF-15, Application for 10-Point Veterans' Preference along with the required documentation listed on the form (such as verification of service-connected disability percentage).
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
Thank you for your interest in Medical Records Technician (Coder Outpatient & Inpatient) with the Martinsburg VA Medical Center located at Martinsburg, WV. Select the appropriate answer to each of the following questions based on your current level of education and/or experience that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that your experience and education are subject to verification by investigation. You may be asked to provide specific examples or documentation of experience or education as proof to support your answers, or you may be required to verify a response by a practical demonstration of your claimed ability to perform a task.
Select “Yes” or “No” to the following question(s).
1.
English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ? 7403(f).
2.
Do you possess or will you possess 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:
- 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).
3.
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
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 have the applicable Certification listed above to qualify for this position? (Note: You MUST upload/submit a valid copy of your certification. Failure to do so will make you ineligible for consideration.)
- Apprentice/Associate Level Certification through AHIMA or AAPC.
- Mastery Level Certification through AHIMA or AAPC.
- Clinical Documentation Improvement Certification through AHIMA or ACDIS.
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 have the applicable Certification listed above to qualify for this position? (Note: You MUST upload/submit a valid copy of your certification. Failure to do so will make you ineligible for consideration.)
Grade Determinations and Assignments.
Medical Records Technician (Coder-Outpatient), GS-8 Qualifications
Assignment. This is the journey level for this assignment. 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. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
Assignment. This is the journey level for this assignment. 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. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
Select “Yes” or “No” to the following question(s).
4.
Medical Records Technician (Coder-Outpatient), GS-8 ( Full Performance Level)
- Experience. One year of creditable experience equivalent to the next lower grade level.
- 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.