Summary This position is located within the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), and the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). The Lead MRT Coder assists in the planning, development, implementation, and maintenance of a coding quality assurance program. Responsibilities The Lead Medical Records Technician (Coder) Outpatient duties include, but are not limited to the following, Assigns codes to document patient care (inpatient and/or outpatient) covering the full range of health care services provided by the VAMC. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Disease (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Monitors ever-changing regulatory and policy requirements affecting coded information to the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as cost recovery programs. Performs a comprehensive review of patient health records to abstract medical, surgical, ancillary, demographic, social and administrative data to ensure complete data capture. Expertly searches the patient health records to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Utilized the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of health record applications (VistA and CPRS) as well as encoder product suite. Orients and instructs new personnel and /or students from affiliated health information or medical records technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple task; works under pressure; and copes with frequently changing projects and deadlines. Monitors the status and progress of work and day to day adjustments in accordance with established priorities. Instructs employees in specific task and job techniques and makes available written instructions, reference materials and supplies. Gives job training to new coders and students to provide the individual with the basic knowledge, skill and ability to perform the full range of the routine and non routine responsibilities required. Trains and works closely with professional administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture. Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Center for Medical & Medicaid Services (CMS) and /or health record documentation guidelines. Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources. Reviews compliance monitors with Supervisors and identifies training needs. Reviews, audits, trains, monitors, and completes special assignments within specified time frames. Required to train others on the encoder product suite. Utilizes this system on an on-going basis to perform core coding duties and audits. Takes the initiative in one-on-one provider training to improve health record documentation for episodes of care. Reports directly to the Coding Supervisor and works independently with minimal supervision. Supervisor identifies limitations such as budgetary or policy constraints and helps the employee with unusual situations which do not have clear precedents. Independently plans, coordinates and carries out assignments in accordance with instructions, policies, previous trainings, and accepted practices in health information management. Work Schedule: 8:00am to 4:30pm Telework: This position is telework eligible and exempted from return to office requirements. This position will be reviewed annually and does not imply permanent telework status. Current employees will be granted an exception to remain in the current duty station and location if outside VISN 8. Virtual: This is not a virtual position. Functional Statement #: 21772F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized 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. 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 dentification 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 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: (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). Certification: Mastery Level Certification through AHIMA or AAPC. Grade Determinations: Experience: One year of creditable experience equivalent to the journey grade level MRT (Coder) Certification: Mastery level certification is required for the Lead Medical Records Technician (Coder). Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. Knowledge of training methods and the ability to provide training to new coding staff. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. 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. The actual grade at which an applicant may be selected for this vacancy is GS-09. 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. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. (3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation. (5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. 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: http://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. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. 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. 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. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
