Job details
Salary $31,520 - $62,894 a year job type full-time
Full job description
Duties
Summary
This position is located in the health information management (him) section for northern indiana health care system (nihcs) at either our marion or fort wayne locationsThe medical records technician (coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.
Responsibilities
This announcement is open to current permanent employees of vanihcs and current permanent employees of department of veteran`s affairs nationwidePer afge master agreement: first area of consideration will go to qualified current permanent employees of va northern indiana health care systemSecond area of consideration will go to all other qualified current permanent employees of department of veteran`s affairs.
** if you are not a current permanent employee of va northern indiana healthcare system or the department of veterans affairs nationwide, you should apply to: cbsr-11243253-21-kdd **
A medical records technician (coder) performs either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding dutiesInpatient 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 proceduresOutpatient 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 servicesCoders directly consult with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record and may also be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (drg)They will also enter and correct information that has been rejected, when necessary, as well as, correct any identified data errors or inconsistencies.
The basic functions of this position are listed below:
Assign codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the vamc.
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 several coding systems to include current versions of the international classification of diseases (icd).
Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management code to ensure ethical, accurate and complete coding.
Work schedule: full timeTypically administrative in natureApplicant must work eastern time zone hoursTour is negotiable, individual schedules will be discussed during the interview process and are subject to change based on the needs of the agency.
Telework: position has approval to be a remote position (employee works 100% of the time in a non-va-owned or leased space either within or outside the local commuting area of parent station).
Fi nancial disclosure report: not required
Physical requirements: see va directive and handbook 5019, employee occupational health service.
The full performance level of this vacancy is gs-08The actual grade at which an applicant may be selected for this vacancy is in the range of gs-04 to gs-08.
References: va handbook 5005/122 part ii appendix g57
Travel required
Occasional travel - you may be expected to travel for this position.
Supervisory status
No
Promotion potential
8
Job family (series)
0675 medical records technician
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Requirements
Requirements
Conditions of employment
You must be a u.sCitizen to Apply Now
All applicants tentatively selected for va employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointmentApplicants who refuse to be tested will be denied employment with va.
Selective service registration is required for males born after 12/31/1959
You may be required to serve a probationary period
Subject to a background/security investigation
Must be proficient in written and spoken english
Selected applicants will be required to complete an online onboarding process
Participation in the seasonal influenza and coronavirus disease 2019 (covid-19) vaccination programs are requirements for all department of veterans affairs health care personnel (hcp)
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.
English language proficiencyMust be proficient in spoken and written english as required by 38 u.s.c§ 7403(f).
CertificationPersons 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.
ExperienceOne year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health recordsOr
EducationAn associate`s degree from an accredited college or university recognized by the u.sDepartment 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 codingThe 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.sDepartment of education accreditor, or comparable; or
Experience/education combinationEquivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsThe 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.sMaritime 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 proceduresAlso, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a mrt (coder).
Grade determinations:
Mrt (coder) outpatient & inpatient, gs-5 experienceOne year of creditable experience equivalent to the next lower grade level; or
EducationSuccessful completion of a bachelor`s degree from an accredited college or university recognized by the u.sDepartment 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.
Demonstrated knowledge, skills, and abilitiesIn addition to the experience above, you must demonstrate all of the following:
Ability to use health information technology and various office software products used in mrt (coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
Ability to navigate through and abstract pertinent information from health records.
Knowledge of the icd cm, pcs official conventions and guidelines for coding and reporting, and cpt guidelines.
Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
Knowledge of the joint commission requirements, cms, and/or health record documentation guidelines.
Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.
Mrt (coder) outpatient & inpatient, gs-6 experienceOne year of creditable experience equivalent to the next lower grade level.
Demonstrated knowledge, skills, and abilitiesIn addition to the experience above, you must demonstrate all of the following:
Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codesThis includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
Ability to apply laws and regulations on the confidentiality of health information (e.g., privacy act, freedom of information act, and hipaa).
Ability to accurately apply the icd cm, pcs official conventions and guidelines for coding and reporting, and cpt guidelines to various coding scenarios.
Comprehensive knowledge of current classification systems, such as icd cm, pcs, cpt, hcpcs, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
Knowledge of complication or comorbidity/major complication or comorbidity (cc/mcc) and poa indicators to obtain correct ms-drg.
Mrt (coder) outpatient & inpatient, gs-7 experienceOne year of creditable experience equivalent to the next lower grade level.
Demonstrated knowledge, skills, and abilitiesIn addition to the experience above, you must demonstrate all of the following:
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 record 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 complete.
Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (cc/mcc), and poa indicators to obtain correct ms-drg.
Mrt (coder) outpatient & inpatient, gs-8 experienceOne year of creditable experience equivalent to the next lower grade level.
Demonstrated knowledge, skills, and abilitiesIn addition to the experience above, you must demonstrate all of the following:
Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentationThis 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.
Education
Important: a transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Transcripts must be official or unofficial college transcriptsA copy of your certificate/degree or screenshot of your current classes are not a replacement of your transcript and they will not be used in the qualifying processYour transcript must include your name and the name and full address of the institution.
If the position has an education requirement or you are qualifying based on education, you need to list your education history including the type of degree and your major of study in your resumeIf the position requires a certain number of credit hours, you are strongly encouraged to list the relevant courses in your resume.
Note: only education or degrees recognized by the u.sDepartment of education from accredited colleges, universities, schools, or institutions may be used to qualify for federal employmentYou 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 educationFor further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
Additional information
Grandfathering provisionAll 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 occupationFor 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.
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 employeeVa may offer newly-appointed federal employee`s credit for their job-related non-federal experience or active duty uniformed military serviceThis credited service can be used in determining the rate at which they earn annual leaveSuch credit must be requested and approved prior to the appointment date and is not guaranteed.
This job opportunity announcement may be used to fill additional vacancies.
It is the policy of the va to not deny employment to those that have faced financial hardships or periods of unemployment.
This position is in the excepted service and does not confer competitive status.
Va encourages persons with disabilities to applyThe health-related positions in va are covered by title 38, and are not covered by the schedule a excepted appointment authority.
Veterans and transitioning service members: please visit the va for vets site for career-search tools for veterans seeking employment at va, career development services for our existing veterans, and coaching and reintegration support for military service members.
If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an alternate application.
How you will be evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
In describing your experience, please be clear and specificWe may not make assumptions regarding your experienceYour application, résumé, c.v., and/or supporting documentation will be verifiedPlease follow all instructions carefullyErrors or omissions may affect consideration for employment.
Do not copy and paste the duties, specialized experience, or occupational assessment questionnaire from this announcement into your resume as that will not be considered a demonstration of your qualifications for this position.
Resume: your resume must thoroughly describe how your skills and experiences align to the criteria defined in the `qualifications` section of this announcement and it must support your responses to the assessment questionnaireWe cannot assume you have performed the necessary experience required for this position regardless of your employment history or academic careerTo ensure all of the essential information is in your resume, we encourage you to use the usajobs online resume builderIf you choose to use your own resume, you must ensure it contains all of the required information and you organize it so we can associate the following information for each experience/position:
Job title
Name of employer
Beginning and ending dates of employment (month/day/year format)
Hours worked per weekWe will prorate part-time employment in crediting experience.
Detailed description of job duties, accomplishments, related skills, and responsibilities to include any supervisory/managerial responsibilities and number of staff supervised (if applicable)
Series and grade or equivalent (if a federal position)
If the position has an education requirement or you are qualifying on the basis of education, you need to list your education history including the type of degree and your major of studyIf the position requires a certain number of credit hours, you are strongly encouraged to list the relevant courses in your resume.
Do not include a photograph or video of yourself, or any sensitive information (age, date of birth, marital status, protected health information, religious affiliation, social security number, etc.) on your resume or cover letterWe will not access web pages linked on your resume or cover letter to determine your qualifications.
For resume writing guidance, please visit the following resources: usajobs resource center, and the usajobs resume writing video tutorial.
To determine your qualifications and referral status, we may review your resume and supporting documentation and compare it against your responses to the vacancy questionnaireEnsure you support your self-ratings by the information you provide in your applicationWe may verify or assess your qualifications at any timeInflated or unsupported qualifications may affect your ratingAny misrepresentation or material omission of facts may be enough cause to end further consideration of your candidacy.
Experience refers to paid and unpaid experience, including volunteer work done through national service programs (e.g., peace corps, americorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social)Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employmentYou will receive credit for all qualifying experience, including volunteer experience.
Background checks and security clearance
Security clearance
Not required
Drug test required
No
Position sensitivity and risk
Non-sensitive (ns)/low risk
Trust determination process
Suitability/fitness
Required documents
Required documents
Please do not submit any other supplementary documentation that is not requested of youTo protect your personal information, we will only send your resume and cover letter to the selecting official or hiring manager.
Note: if more than one resume is submitted with your application package, only the most recent resume will be reviewed.
To apply for this position, you must provide a complete application package which includes:
Resume
Sf-50/ notification of personnel action.
To verify your eligibility, you must submit a copy of your most recent notification of personnel action (dated in the year 2021), standard form 50 (sf-50)You may obtain a copy of your sf-50 from your eopfFailure to provide this will exclude you from your claimed eligibility.
Copy of certification: 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.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this positionPlease 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 (current/former federal employees), etc.
Cover letter
Dd-214/ statement of service
Disability letter (schedule a)
Disability letter (va)
Va form 10-2850c application for associated health occupations can be found at: https://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf.
Other (2)
Other (3)
Performance appraisal
Professional certification
Sf-15
Transcript
This announcement is open to current permanent employees of vanihcs, current permanent employees of department of veteran`s affairs nationwidePer afge master agreement: first area of consideration will go to qualified current permanent employees of va northern indiana health care systemSecond area of consideration will go to all other qualified current permanent employees of department of veteran`s affairs.
** if you are not a current permanent employee of va northern indiana healthcare system or the department of veterans affairs nationwide, you should apply to: cbsr-11243253-21-kdd**
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the u.sDepartment of education in order for it to be credited towards qualificationsTherefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the u.sDepartment of education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
Benefits
Benefits
A career with the u.sGovernment provides employees with a comprehensive benefits packageAs a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewardingOpens in a new windowlearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittentContact the hiring agency for more information on the specific benefits offered.
Help
This job is open to
Internal to an agency
Current federal employees of this agency.
Clarification from the agency
Open to current permanent employees of the department of veterans affairs1st area of consideration - qualified current permanent employees of va northern indiana health care system2nd area of consideration - qualified current permanent va employees nationwide** if you are not a current permanent employee of the department of veterans affairs, you should apply to: cbsr-11243253-21-kdd **
