This position is located in the Health Information Management (HIM) section at the Alaska VA Health Care System. The 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.
Recruitment/Relocation Incentives are not approved.
Telework: May be authorized for highly qualified candidates.
Virtual: May be authorized for highly qualified candidates.
Duties include but are not limited to:
Assigns codes to documented patient care encounters (outpatient) covering the full range of health care services provided by the VA Medical Center.
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), 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 code to ensure ethical, accurate, and complete coding.
Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA Medical Center.
Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
Reports incorrect documentation or codes in the electronic patient health record.
Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Work Schedule: Monday
Friday, 8:00 am
4:30 pm (subject to change at the discretion of the department)
Financial Disclosure Report: Not required
Job family (Series)
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
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 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.
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.
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.
Coding Certification highly desired.
References: VA Handbook 5005, Part II, Appendix G35, Medical Record Technician Qualification Standard, GS-675, available in the local Human Resources Office.
The full performance level of this vacancy is GS-08.
The work is primarily sedentary, light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers, both hands; may require some walking and standing; far vision correctable in one eye to 20/20 and to 20/40 in the other, depth perception; hearing (aid permitted).
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: .
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.
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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
Drug test required
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: . Please submit at time of application.
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).
Service Connection Letter
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.
Veterans Affairs, Veterans Health Administration