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Lead Medical Record Technician(Coder)

Expired Job

Veterans Affairs, Veterans Health Administration Bronx , NY 10451

Posted 5 months ago



The James J. Peters VA Medical Center is seeking a full-time Lead Medical Records Technician (Coder) to join our Business Service.

The Lead Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification system appropriate for the type of care provided. The Lead Medical Records Technician (Coder) reviews coding and assists coders 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 analyzes data; and may also coordinate, assign, and monitor the workflow.

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 service and the organizational structure to ensure proper code selection.

Work Schedule: Monday-Friday,8:00 AM-4:30 pm
Financial Disclosure Report: Not required

Travel Required

Not required

Supervisory status


Promotion Potential


Job family (Series)

Similar jobs


Conditions of Employment

You must be a U.S. Citizen to apply for this job
Designated and/or random drug testing may be required
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


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 must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
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.
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).
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: AHIMA or AAPC Coding Certification (CCS, CCS-P, CPC, COC, and CIC) preferred.

Grade Determinations: In addition to the qualification above you must also have specialized experience.

GS-09 Specialized Experience: You must possess one year of specialized experience equivalent to the GS-08 level in the Federal Service.

Specialized experience is defined as experience which equipped you with the particular knowledge, skills, and abilities to perform successfully the duties of the Lead Medical Record Technician (Coder), and that is typically in or related to the work of the position. Examples of specialized experience include but are not limited to: Reviewing inpatient documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures; reviewing outpatient 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; consulting with professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record; abstracting and sequencing codes into encoder software to obtain correct diagnosis-related group (DRG); entering and correcting information that has been rejected; and correcting any identified data errors or inconsistencies.

Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate the following KSAs:

Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities of a medical record function in order to effectively complete job duties of assignment such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc.;
Comprehensive knowledge of medical record technology theories, methods, procedures, and techniques for assigned areas;
Ability to communicate tactfully and effectively, both orally and in writing, in order to meet program objectives. This may include preparing reports in various formats and presenting data to various organizational levels. References: VA Handbook 5005/79, Part II, Appendix G35

The full performance level of this vacancy is GS-9.


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: . 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: .

Additional information

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 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 .

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 SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, rsum, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

NOTE: The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and salary at which the candidate will be placed. For internal selectees eligible for promotion, the board will determine grade and HR will determine step in accordance with policy.

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.

Background checks and security clearance

Security clearance

Drug test required


Required Documents

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


VA Form 10-2850c Application for Associated Health Occupations can be found at: .

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this 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).

Cover Letter
Other Veterans Document

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 .

If you are relying on your education to meet qualification requirements:

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 .
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.

This job originated on . For the full announcement and to apply, visit . Only resumes submitted according to the instructions on the job announcement listed at will be considered.

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Lead Medical Record Technician(Coder)

Expired Job

Veterans Affairs, Veterans Health Administration