Medical Records Technician; Inpatient Coder

Position: Medical Records Technician (Inpatient Coder)

This position is eligible for remote work and is currently operating under an extension of the Return-to-Office (RTO) mandate. Please note that remote work eligibility is reviewed on an ongoing basis and does not imply a permanent remote work status until an exemption is approved. Employees in this role may be required to comply with future RTO requirements as determined by agency policy.

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 (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience and
  
  Education:
  
  
  • Experience
    . One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR,
  • Education
    . An associate's degree from an accredited college or university recognized by the U.S. Department 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 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;
  • Experience/Education Combination
    . Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations

Medical Records Technician (Coder-Inpatient), GS-5

• Experience. One year of creditable experience equivalent to the next lower grade level; OR,
• Education. Successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department 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 Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • i. 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.).
  • ii. Ability to navigate through and abstract pertinent information from health records.
  • iii. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting.
  • iv. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation.
  • v. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
  • vi. Ability to manage priorities and coordinate work to complete duties within required time frames and the ability to follow-up on pending issues.

Medical Records Technician (Coder-Inpatient), GS-6

• Experience. One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
  • ii. Ability to determine whether…