Summary The Medical Records Technician (Coder) position is located within the Health Information Management (HIM) section at the William S. Middleton Memorial Veterans Hospital in Madison, WI. This announcement will be used to fill vacancies at The William S. Middleton Memorial Veterans Hospital in Madison, WI. Responsibilities Total Rewards of a Allied Health Professional Major Duties: Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services. Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS), Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic. Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts supervisor when needed. Work Schedule: Monday-Friday 8:00 am- 4:30 pm Remote: Yes Telework: Yes Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Functional Statement #: 000000 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). May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation. Experience and Education: GS-4 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 one of the above examples of experience and/or education? Possess any of the following certifications, which are required for appointment or reassignment to MRT (Coder) positions in the GS-0675 series in VHA. Copy of certification required. Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determinations: GS-5 level Experience or Education: Experience: Possess 1 year of creditable experience comparable to the next lower grade level (GS-4) OR, Education: Successfully completed 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. In addition, you must demonstrate KSAs for this grade: GS-6 level Experience: Experience: Possess at least one full year of creditable experience as an MRT (Coder - Outpatient and Inpatient) to the next lower level (GS-5). Experience must demonstrate all of the KSAs for this grade. GS-7 level Experience: Experience: I possess at least one full year of experience as an MRT (Coder - Outpatient and Inpatient) equivalent to the next lower level (GS-6). Experience 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 care 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 completed; and ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indictors to obtain correct MS-DRG. GS-8 level Experience: Experience: Possess at least one full year of creditable experience as an MRT (Coder-Outpatient and Inpatient) equivalent to the next lower level (GS-7). Experience must demonstrate all of the following KSAs: Ability to analyze the medical 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 medical 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/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines. A minimum of three (3) years of coding experience in the occupation as an MRT (Coder - Outpatient and Inpatient) is required to qualify at this grade level. Three (3) years of post-bachelor's degree experience or four (4) years of post-basic experience/education required to qualify at this grade level. 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-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: Analyzes medical records for completeness, consistency, and compliance with requirements; medical record data. Application of practical knowledge of medical terminology, anatomy, physiology, internal organization and consistency of the medical record, medical record reference and procedures, and medical and legal significance of the medical records. 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.
