Summary This position is located in the Health Information Management (HIM) section of the Health Administration Service (HAS) at the James E. Van Zandt VA Medical Center. Incumbent is required to reside within 50 miles of VA Altoona. Responsibilities Total Rewards of a Allied Health Professional Medical Records Technician (Coder) Auditor are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Applies comprehensive 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. Reviews assigned codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Reviews, analyzes, and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding. Reviews coding and assist clinical staff in improving coding accuracy. Provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations. Initiates various reports and analyze data. Performs other duties as may be assigned. Work Schedule: 8:00am -4:30pm, Monday to Friday Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). 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. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. 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) Telework: This position is 100% telework eligible; incumbent is required to reside within 50 miles of VA Altoona. Virtual: This is not a virtual position. Functional Statement #: Medical Records Technician (Coder) Auditor (Inpatient/Outpatient) / 000000 Permanent Change of Station (PCS): 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 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. 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 4 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: 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. English Language Proficiency.: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f) Grade Determinations: Medical Records Technician (Coder) Auditor GS-9 (Above the Full Performance level) Experience: Must posses one year of creditable experience equivalent to the next lower grade level GS-8 level.(Select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and/or outpatient records; 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; 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; directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record; 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; review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature; query clinical staff with documentation requirements to support the coding process; enter and correct information that has been rejected, when necessary; correct any identified data errors or inconsistencies; ensure audit findings have been corrected and refiled; and use various computer applications to abstract records, assign codes, and record and transmit data) Certification: Must possess mastery level certifications through AHIMA or AAPC. In additional to the experience above you must demonstrate the following Knowledge, Skills and Abilities: Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. 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-9. The actual grade at which an applicant may be selected for this vacancy is GS-9 Physical Requirements: See VA Directives and Handbook 5019, Employee Occupational Health Service. 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 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: 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. 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. 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. 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. 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. Receiving Service Credit for 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.
