The Medical Records Technician is a staff position located in the Coding Unit of the Health Information Management Section of the Medical Administration Service (MAS) at the West Palm Beach Veterans Affairs Center (WPB VAMC) The duties and responsibilities are carried out throughout the medical center including all administrative and clinical areas involved with the service
The Medical Record Technician (Coder Outpatient & Inpatient) is responsible for the coding of information from the medical record of patients to generate a clinical patient care database for this facility. Duties include:
Work Schedule: Monday – Friday 0800-1630 (*Please note: Work schedules will be based off the needs of the facility and will be determined by management.)
Telework: May be offered to highly qualified individuals.
Virtual: This is not a virtual position.
Financial Disclosure Report: Not required
Occasional travel – You may be expected to travel for this position.
0675 Medical Records Technician
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
SPECIALIZED EXPERIENCE: One year of specialized experience equivalent to the next lower grade level.
Preferred Experience: Preferred Coding Certification, Previous coding experience: ICD-10CM International Classification of Diseases (ICD) Clinical Modifications (CM), and/or Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System ( HCPCS)
CERTIFICATION: Employees at this level must have at least one of the certifications below:
1. Apprentice/Associate Level Certification through AHIMA or AAPC.
2. Mastery level certification through AHIMA or AAPC (CCS, CCS-P, CPC, RHIT, RHIA).
3. Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of the VA 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 the GS-08: Experience or education as stated in the basic requirements and specialized experience above. In addition, the candidate must demonstrate the following KSAs:
ASSIGNMENT: This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They 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. They 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. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
References: VA Handbook 5005/122 Part II, Appendix G-57, Medical Record Technician Qualification Standard.
The full performance level of this vacancy is GS-08.
Physical Requirements: The work is sedentary. However, there may be long periods walking, standing, and bending
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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
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 apply. The 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 view the following link for information regarding an Alternate Application.
You will be evaluated for this job based on how well you meet the qualifications above.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
NOTE: A formal pay-setting process will be used to determine your salary. The salary may be at any point in the range listed for this vacancy.
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 employment. You will receive credit for all qualifying experience, including volunteer experience.
Non-sensitive (NS)/Low Risk
To apply for this position, you must provide a complete Application Package which includes:
VA Form 10-2850 can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search.
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 (current/former Federal employees), etc.
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.
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department 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.
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U.S. citizens, nationals or those who owe allegiance to the U.S.