Medical Records Tech; Coder-Inpatient

U.S. Department of Veterans Affairs Provided Pay Range

U.S. Department of Veterans Affairs provided pay range

$36,049.00/yr - $71,932.00/yr

The 2-page resume requirement does not apply to this occupational series. For more information refer to "Required Documents" below. The position is located in the Health Information Management (HIM) section at the Salem, Virginia VA Medical Center. Medical Records Technicians (Coders) classify medical data from patient health records in hospital settings and/or physician-based settings such as physician offices, group practices, multi‑specialty clinics, and specialty centers.

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:
  Proficient in spoken and written English as required by 38 USC 7403(f).
• Experience and
  
  Education:
  
  At least one year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records; OR an associate’s degree in health information technology/health information management with a minimum of 12 semester hours (or a related degree with a minimum of 12 semester hours).
• Completion of an AHIMA‑approved coding program or an intensive coding training program of approximately one year or more that included courses in anatomy & physiology, medical terminology, basic ICD diagnostic/procedural coding, and basic CPT coding. The program must have led to eligibility for coding certification.
• Equivalent combinations of creditable experience and education that meet the basic–requirements:
  • (a) Six months of creditable experience indicating knowledge of medical terminology and basic medical coding plus one year of post‑high‑school education with at least 6 semester hours of health information technology courses.
  • (b) Successful completion by a medical technician, hospital corpsman, or medical service specialist in the Armed Forces or the U.S. Maritime Service under close medical supervision, covering courses in anatomy & physiology and health‑record techniques and procedures, which may substitute for up to six months of experience.
• Certification:
  Persons hired or Geg ______ to MRT (Coder) positions in the GS‑0675 series must have either:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Grandfathering Provision may apply to current VHA employees pursuant to the VA Qualification Standard for this occupation.

• Medical Records Technician (Coder‑Inpatient) – GS‑04:
  • Experience or
    
    Education:
    
    None beyond basic requirements.
• Medical Records Technician (Coder‑Inpatient) – GS‑05:
  • (a)
    
    Experience:
    
    One year of creditable experience equivalent to the next lower grade level.
  • (b)
    
    Education:
    
    Successful completion of a bachelor’s degree in health information management or a related field with a minimum of 24 semester hours.
  • (c) KSAs:
    • Use of health information technology and office software used in MRT (Coder) positions.
    • Navigate through and abstract pertinent information from health records.
    • Knowledge of ICD‑CM and PCS Official Conventions and Guidelines for Coding and Reporting.
    • Apply medical terminology, human anatomy/physiology, and disease processes to assign accurate codes.
    • Knowledge of The Joint Commission requirements, CMS, and health‑record documentation guidelines.
    • Manage priorities and coordinate work to meet deadlines, following up on pending issues.
• Medical Records Technician (Coder‑Inpatient) – GS‑06:
  • (a)
    
    Experience:
    
    One year of creditable experience equivalent to-field level.
  • (b) KSAs:
    • Analyze health records to identify all pertinent diagnoses and procedures, evaluate documentation adequacy.
    • Determine compliance with regulatory requirements, legal documentation adequacy, continuity of patient care, and support assignment.
    • Take action if record contents are incomplete, inaccurate, timely, or reliable.
    • Apply laws on confidentiality of health information…