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Job Title: Medical Records Tech (Coder)
Company Name: Veterans Affairs, Veterans Health Administration
Location: Lexington, KY
Position Type: Full Time
Post Date: 09/12/2018
Expire Date: 11/11/2018
Job Categories: Computers, Software, Government and Policy, Healthcare, Other, Healthcare, Practitioner and Technician, Information Technology, Insurance, Internet/E-Commerce, Research & Development, Medical, Web Technology
Job Description
Medical Records Tech (Coder)

The MRT - Coder is responsible for reviewing the electronic medical record to ensure the most appropriate codes are assigned, and is responsible for entering information into the appropriate software package(s) and maintaining a control system to track any changes.

The MRT - Coder will work closely with the members of the healthcare team, particularly the providers, to provide support and technical guidance relative to the selection of the most appropriate diagnosis and procedure codes. This position requires on-going, face-to-face interaction with clinical staff, and will involve time spent in clinical locations as an embedded part of the care team.

Please note that the initial grade/salary of this position will be determined via the Hybrid Title 38 boarding process after the employee is hired. Grade/salary will be based on the candidate's education and/or coding experience. This position will qualify for advancement to the full performance level (GS-8) after performance requirements for each lower grade are met and maintained for an established time period.

Work Schedule: Mon-Fri, 8:00am-4:30pm
Financial Disclosure Report: Not required

Basic Requirements
a. Citizenship. Citizen of the United States.
b. Experience and Education
(1) Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.
OR,
(2) Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).
OR,
(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.

Preferred Experience: Prior coding experience in multi-disciplinary outpatient setting(s), surgical procedure coding, and/or inpatient (DRG) coding is preferred. Preferred candidate will possess a credential through either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

Grade Determinations:
a. MRT (Coder)
(1) GS-4 MRT (Coder) - Entry Level
(a) Experience or Education. None beyond basic requirements.
(b) Assignment. Employees at this level serve as entry level MRT coders and receive close supervision from more experienced MRT Coders.
(2) GS-5 MRT (Coder) Developmental Level 1
(a) Experience. One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.);
2. Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and
3. Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues.
(c) Assignment. Employees at this grade level serve as developmental MRT coders and receive guidance from more experienced staff members for more complex coding procedures.
(3) GS-6 MRT (Coder) Developmental Level 2
(a) Experience. One year of experience equivalent to the next lower level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to navigate through health records to find needed information;
2. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines;
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and
4. Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation.
(c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring. Coders may perform either inpatient or outpatient coding duties or may perform a combination of inpatient and outpatient coding.
(4) GS-7 MRT (Coder) Developmental Level 3
(a) Experience. One year of experience equivalent to the next lower grade level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record;
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment;
3. Ability to research and solve coding and documentation related issues; and
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
(c) Assignment. Employees at this grade level serve as developmental MRT coders and receive minimal monitoring. Coders may perform either inpatient or outpatient coding duties or may perform a combination of inpatient and outpatient coding.
(5) GS-8 MRT (Coder) Full Performance Level
(a) Experience. One year of experience equivalent to the next lower grade level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. 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;
2. 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; and
3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.
(c) Assignment. This is considered to be the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services.
Directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies.

None

To apply for this position, you must provide a complete Application Package which includes:

  • Resume

1. Resume: Due to new OPM requirements you must have the following information on your resume:
a. Applicants Full complete address, Job locations, and Education (street, city, state, & zip code)
b. All Education Full Street Address (P.O. Box addresses are not acceptable)
c. Dates of Attendance must be in MM/YYYY format and include To: and From: (If exact dates are unknown, please provide estimated MM/YYYY and indicate estimated)
d. All Work Related Experience must have Full Street Address (P.O. Box addresses are not acceptable)
e. Dates of Employment/Experience Activity must be in MM/YYYY format and include To: and From: (If exact dates are unknown, please provide estimated MM/YYYY and indicate estimated).

2. VA Form 10-2850c - Application for Associated Health Occupations (required). (Available at the VA Forms Website: http://www.va.gov/vaforms/search_action.asp?FormNo=10-2850&tkey=&Action=Search)

a. In the Additional Education section, please submit Full address (street, city, state,& zip code).
b. In the Professional Experience section, please submit Full address.
c. In the Reference section, make sure you have the full addresses for each reference listed

3. Current SF-50(s), Notification of Personnel, showing title, series, grade/step/salary. (Required for current or former government employees) Note: Your SF-50 should reflect the grade and step information equivalent to or greater than the grade lower than the position you are applying to as well as showing the length of time in grade requirements. This may not always be your most recent SF-50. You may need to submit more than one SF-50.

4. Copy of your transcript if you are using education to qualify or specified "required"

5. Responses to the Occupational Questionnaire.

6. Veterans Preference documentation such as DD-214 or equivalent, SF-15 and VA Letter, as appropriate.

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, documentation to support Veterans Preference or ICTAP/CTAP documentation (for displaced Federal employees).

  • DD-214
  • OF-306
  • 10-2850c
  • VA Disability Letter
  • Resume
  • SF-15
  • SF-50
  • Transcript


Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx.
Qualifications & Requirements
Basic Requirements
a. Citizenship. Citizen of the United States.
b. Experience and Education
(1) Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.
OR,
(2) Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).
OR,
(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.

Preferred Experience: Prior coding experience in multi-disciplinary outpatient setting(s), surgical procedure coding, and/or inpatient (DRG) coding is preferred. Preferred candidate will possess a credential through either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

Grade Determinations:
a. MRT (Coder)
(1) GS-4 MRT (Coder) - Entry Level
(a) Experience or Education. None beyond basic requirements.
(b) Assignment. Employees at this level serve as entry level MRT coders and receive close supervision from more experienced MRT Coders.
(2) GS-5 MRT (Coder) Developmental Level 1
(a) Experience. One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.);
2. Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and
3. Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues.
(c) Assignment. Employees at this grade level serve as developmental MRT coders and receive guidance from more experienced staff members for more complex coding procedures.
(3) GS-6 MRT (Coder) Developmental Level 2
(a) Experience. One year of experience equivalent to the next lower level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to navigate through health records to find needed information;
2. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines;
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and
4. Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation.
(c) Assignment. Employees at this grade level serve in developmental positions as MRT coders and receive intermittent monitoring. Coders may perform either inpatient or outpatient coding duties or may perform a combination of inpatient and outpatient coding.
(4) GS-7 MRT (Coder) Developmental Level 3
(a) Experience. One year of experience equivalent to the next lower grade level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record;
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment;
3. Ability to research and solve coding and documentation related issues; and
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
(c) Assignment. Employees at this grade level serve as developmental MRT coders and receive minimal monitoring. Coders may perform either inpatient or outpatient coding duties or may perform a combination of inpatient and outpatient coding.
(5) GS-8 MRT (Coder) Full Performance Level
(a) Experience. One year of experience equivalent to the next lower grade level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. 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;
2. 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; and
3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.
(c) Assignment. This is considered to be the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services.
Directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies.

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Contact Information
Contact Name:
Company Name: Veterans Affairs, Veterans Health Administration
Phone Number:
Fax Number:
Contact Email:KristinE.Harris@va.gov
Website:http://www.ecentralmetrics.com/url/?u=137011020267%2D254&r=http%3A%2F%2Fwww%2Evacareers%2Eva%2Egov%2Fjob%2Dsearch%2Fjob%2Ddetail%2Easp%3Fjob%3D350841
Company Description:

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