Medical Records Technician-Medical Coder

<p>This position is in the Health Information Management (HIM) section of Patient Business Services (PBS) at the Columbus VA Ambulatory Care Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.</p><h3>Major Duties</h3><p>Coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. Outpatient Medical Record Technicians (Coder) select and assign codes to outpatient episodes of care, and/or inpatient professional services from current versions of ICD-10-CM, CPT, and HCPCS classification systems.Duties include but are not limited to: Utilize the facility computer system and software applications to code, abstract, record, and transmit data. Correct any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Research references to resolve any questionable code errors; contact a senior coder or supervisor when needed. Work within a team environment; support peers in meeting goals and deadlines; flexible and handle multiple tasks; work under pressure; and cope with frequently changing projects and deadlines. Adhere to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Adhere to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VMCC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Perform a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided; provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensure provider documentation is complete and supports the diagnoses and procedures coded. Directly consult with the professional staff for clarification of conflicting or ambiguous clinical data. Report incorrect documentation or codes in the electronic patient health record. Work Schedule: Monday-Friday 7:30am-4:00pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: This position is designated as telework eligible. Telework refers to a flexible arrangement which an employee, under a written telework agreement, performs the duties and responsibilities of such employee's position, and other authorized activities, from an approved worksite other than the (VA facility or VA-leased space) from which the employee typically works from. The telework arrangement may be "regular, recurring" or "situational (ad hoc)".The option for telework will be assessed continuously, and the selected individual may need to return to a VA office if required. Virtual: This is not a virtual position. Functional Statement #: #:91719-0, 91720-0, 91721-0, 91722-0, 91723-0 Permanent Change of Station (PCS): Not Authorized</p><h3>Requirements</h3>You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.<h3>Education</h3>Medical Records Technician (Coder-Outpatient), GS-8 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: Ability to analyze the health 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 health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines. Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08 Physical Requirements: The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, records, or driving an automobile, etc. No special physical demands are required to perform the work. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.