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Coder Jobs

Avem Health Partners

Department of Veterans Affairs

Norman Regional Health System

Remote

Onsite

JOB PURPOSE: To abstract and code compliantly, accurately and completely as well as group each account to the appropriate DRG to facilitate data quality and ensure accurate and timely reimbursement. Verifies reviews, analyzes, and abstracts medical information; researches missing medical information; assigns accurate codes; appropriately queries physicians when required; elevates documentation issues to management; ensures valid orders are on the record prior to coding; communicates with HIM Director regarding obstacles with orders, charges, physician documentation. Demonstrates proficiency in the coding and grouping of inpatient accounts.

&nbsp;

ESSENTIAL FUNCTIONS INCLUDE BUT NOT LIMITED TO:

<ul>
	<li style="text-align:justify;">Assures data quality by capturing codes and data while complying with NCCI, while maintaining a 95% or higher accuracy rate as validated by audit.</li>
	<li style="text-align:justify;">Demonstrates consistent and efficient performance by coding a minimum of 3.5 to 4 inpatient accounts per hour. </li>
	<li style="text-align:justify;">Queries physicians as necessary to clarify missing, ambiguous, incomplete or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding.</li>
	<li style="text-align:justify;">Notifies HIM Director and Manager of Revenue Cycle when the admission order is missing or not signed prior to discharge.</li>
	<li style="text-align:justify;">Accurately abstracts information from the medical record into the abstracting module.</li>
	<li style="text-align:justify;">Demonstrates competencies with software systems in use for the HIM coding staff.</li>
	<li style="text-align:justify;">Collaborates with Director on Coding Queries.</li>
	<li style="text-align:justify;">Serves as a resource to other coders.</li>
	<li style="text-align:justify;">Manages time and workload with understanding of the relationship between coding accuracy, timeliness and deadlines.</li>
	<li style="text-align:justify;">Keeps current of all changes in coding by reading all new Coding Clinics and CPT Assistants annually.</li>
	<li style="text-align:justify;">Complete a minimum of 10 hours of formal education and 10 hours of informal education (reading coding clinics and CPT Assistant), which can be turned to formal by taking the quiz on the back and submitting for credit.</li>
	<li style="text-align:justify;">Performs additional responsibility as directed.</li>
</ul>

&nbsp;

BEHAVIORAL STANDARDS

<ul>
	<li>The individual must support the mission, vision, and goals of Avem Health Partners and serve as a role model within the company.</li>
	<li>Exhibit positive customer service behavior in every day work interactions.</li>
	<li>Demonstrate a courteous and respectful attitude to internal workforce and external customers.</li>
	<li>Communicate accurately and appropriately.</li>
	<li>Handle difficult situations in a discreet and professional manner.</li>
	<li>Hold self-accountable for professional practice.</li>
	<li>Participate in performance improvement activities utilizing principles to support and improve departmental goals.</li>
	<li>Demonstrate knowledge of unit goals and is active in committees and projects to achieve these goals.</li>
	<li>Keep current with literature regarding changing practices, interventions and best practices.</li>
	<li>Assume responsibility for seeking out educational and professional opportunities for personal learning needs and growth as well as meeting mandatory education requirements.</li>
	<li>Act as a preceptor as requested.</li>
	<li>Demonstrate excellent work attendance and actively participate in a variety of meetings and training sessions as required.</li>
	<li>Adhere to the Avem Health Partners Code of Conduct and Standards of Behavior. Complies with established policies and procedures and all health and safety requirements.</li>
</ul>

&nbsp;

EDUCATION/QUALIFICATIONS:

<ul>
	<li style="text-align:justify;">Graduate of an AHIMA coding program, RHIT or RHIA program. </li>
	<li style="text-align:justify;">AS or BS degree preferred.</li>
	<li>Minimum 3-5 years inpatient coding experience preferred or equivalent combination of education and experience.</li>
	<li>High level of competence in inpatient coding, DRG grouping, ICD-10 diagnostic and procedural code assignment</li>
	<li>Competency related to coding of outpatient record types.</li>
	<li>Passing score on company coding test.</li>
	<li>Possesses basic knowledge of HIM principles and department functions.</li>
	<li>Possesses advanced knowledge of ICD&mdash;10CM and ICD-10PCS coding rules and conventions.</li>
	<li>Possesses advanced knowledge of medical terminology, anatomy and physiology, disease processes and pharmacology.</li>
	<li>Ability to read and analyze all aspects of medical record documentation for accurate and complete coding.</li>
	<li>Possesses a thorough knowledge of the encoder system.</li>
	<li>Experienced and highly knowledgeable in the DRG/MSDRG grouping system.</li>
	<li>Ability to abstract information from the medical record for indices and statistical reports.</li>
	<li>Excellent PC and software utilization skills.</li>
	<li>Ability to work independently.</li>
</ul>

&nbsp;

CERTIFICATION/LICENSURE:

<ul>
	<li>CCS, CPC, RHIT or RHIA credentialed by American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC)</li>
</ul>

&nbsp;

PHYSICAL REQUIREMENTS:

<ul>
	<li>To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant to be considered.</li>
	<li>This job requires visual abilities and auditory abilities, must be intact to perform duties.</li>
	<li>Must be able to perform repetitive tasks/motions.</li>
</ul>

Inpatient Coder

Certified inpatient coder with experience in DRG grouping and ICD-10 coding; strong data quality and auditing skills; ability to query physicians and collaborate with HIM leadership.

JOB PURPOSE:&nbsp; The Lead Coder will be able to code all patient types as needed; inpatient, swing bed, same-day surgery, ancillary, ambulatory and provider-based clinics. This individual will mentor, train and assist with cross training coding staff, including newly hired coding staff. Must be familiar with reviewing documentation to assign appropriate CPT/HCPCS and ICD-10-CM-PCS diagnosis codes and procedures for hospital and physician (professional) services for Inpatient and Outpatient records based on knowledge of coding systems, including ICD-10-CM/PCS and CPT/HCPCS.

&nbsp;

ESSENTIAL FUNCTIONS INCLUDE BUT NOT LIMITED TO:

<ul>
	<li>Ensures that coding compliance initiatives are met with all record types. </li>
	<li>Conducts regular internal coding audits and quality assurance reviews to monitor coding accuracy, identify areas for improvement, and implement corrective measures and education as needed.&nbsp; </li>
	<li>Assist with productivity reporting and reducing DNFC. </li>
	<li>Codes complex outpatient or inpatient accounts utilizing encoder software and references in the assignment of ICD-10-CM/PCS, CPT/HCPCS codes, DRG, POA assignments, APC assignment and all required modifiers.</li>
	<li>Validates charges by comparing charges with health record documentation as necessary, adding procedure and professional charges as appropriate.</li>
	<li>Identifies concerns and notifies appropriate leadership for resolution. Responsible for providing resolution to moderate to complex problems.</li>
	<li>Tracks issues (i.e. missing documentation, charges and physician queries) that require follow-up to facilitate coding in a timely fashion.</li>
	<li>Consistently meets or exceeds coding quality and productivity standards established by coding department. </li>
	<li>Adheres to confidentiality requirements as they relate to release of any individual or aggregate patient information.</li>
	<li>Maintains up-to-date knowledge of changes in coding and reimbursement guidelines and regulations. </li>
	<li>Performs other duties as assigned by leadership.</li>
	<li>Maintains working knowledge of applicable coding and reimbursement Federal, State and local laws and regulations, the Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. </li>
	<li>Extensive comprehensive working knowledge of medical terminology, anatomy and physiology, ICD-10-CM/PCS diagnostic and procedural coding including CPT/HCPCS and DRG or APC grouping coding principles and guidelines.</li>
	<li>Experience utilizing coding references, encoder software tools, and electronic health records (EHR) to facilitate accurate and efficient code assignment.</li>
	<li>Ability to use standard desktop and windows-based computer system, including basic understanding of email, internet, and computer navigation.</li>
	<li>Maintain a high level of accuracy in code assignment to prevent claim denials, billing errors, and potential legal issues.</li>
	<li>Communicates effectively with clinical staff, physicians and office staff and Clinical Documentation Improvement Specialist to clarify documentation, to resolve coding-related queries, and to ensure accurate and timely claim submission and reimbursement related to Inpatient, Outpatient, or Ambulatory coding.</li>
	<li>Participate in ongoing education, training, and certification programs to enhance coding proficiency and maintain credentials.</li>
	<li>Uphold professional ethics, integrity, and confidentiality in handling patient information.</li>
	<li>Extensive knowledge of hospital and professional coding including provider-based billing.</li>
	<li>Other duties as assigned.</li>
</ul>

&nbsp;

BEHAVIORAL STANDARDS

<ul>
	<li>The individual must support the mission, vision, and goals of Avem Health Partners and serve as a role model within the company.</li>
	<li>Exhibit positive customer service behavior in every day work interactions.</li>
	<li>Demonstrate a courteous and respectful attitude to internal workforce and external customers.</li>
	<li>Communicate accurately and appropriately.</li>
	<li>Handle difficult situations in a discreet and professional manner.</li>
	<li>Hold self-accountable for professional practice.</li>
	<li>Participate in performance improvement activities utilizing principles to support and improve departmental goals.</li>
	<li>Demonstrate knowledge of unit goals and is active in committees and projects to achieve these goals.</li>
	<li>Keep current with literature regarding changing practices, interventions and best practices.</li>
	<li>Assume responsibility for seeking out educational and professional opportunities for personal learning needs and growth as well as meeting mandatory education requirements.</li>
	<li>Act as a preceptor as requested.</li>
	<li>Demonstrate excellent work attendance and actively participate in a variety of meetings and training sessions as required.</li>
	<li>Adhere to the Avem Health Partners Code of Conduct and Standards of Behavior. Complies with established policies and procedures and all health and safety requirements.</li>
</ul>

&nbsp;

EDUCATION/QUALIFICATIONS:

<ul>
	<li>High School diploma or equivalent and Medical Coding Education. Preferred bachelor&rsquo;s degree in Health Information Management, Business Administration or related field.</li>
	<li>Three (3) years of verifiable, progressive coding experience. Preferred more than five (5) years of coding experience in an acute care hospital setting.</li>
</ul>

&nbsp;

CERTIFICATION/LICENSURE: 

<ul>
	<li>Certified Coding Specialist (CCS) Required or equivalent.</li>
</ul>

&nbsp;

PHYSICAL REQUIREMENTS:

<ul>
	<li>To perform this job successfully, an individual must be able to perform each essential job duties satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant to be considered.</li>
	<li>This job requires visual abilities, auditory abilities, must be intact to perform duties.</li>
</ul>

Lead Medical Coder

Three years of progressive coding experience; CCS certification required; High school diploma with medical coding education; Bachelor's degree preferred.

JOB PURPOSE: This position is for an Outpatient Coder with Emergency Dept and Ambulatory Surgery coding experience. The coder will code Surgery, Emergency department, and Ancillary records. Emergency Dept coding includes injection &amp; infusion coding as well as the assignment of the E&amp;M Professional fee. Coder will demonstrate competency by meeting productivity standards and achieving an accuracy rate of 95% on all chart types coded. 

&nbsp;

Will abstract and code every account compliantly, accurately, and completely, to ensure accurate and timely reimbursement and reporting. Verifies, reviews, analyzes, and abstracts medical information; researches missing clinical information; assigns accurate codes; appropriately queries physicians when required; elevates documentation issues to management; ensures valid orders are on the record prior to coding; communicates with Coding Manager daily regarding obstacles that prevent a chart from being coded. Demonstrates proficiency in the coding of these outpatient accounts.

&nbsp;

ESSENTIAL FUNCTIONS INCLUDE BUT NOT LIMITED TO:

<ul>
	<li style="text-align:justify;">Assures data quality by maintaining a 95% or higher accuracy rate as validated by audit.</li>
	<li style="text-align:justify;">Demonstrates consistent and efficient performance by coding a minimum of 12-15 ED records per hour, 7 outpatient surgery records per hour, 7 observation records per hour, 25-30 outpatient diagnostic accounts per hour.</li>
	<li style="text-align:justify;">Ensures there is a valid physician order for all outpatient surgery accounts. </li>
	<li style="text-align:justify;">Ensures proper verbiage on all observation orders. </li>
	<li style="text-align:justify;">Ensures a valid physician/provider order for all outpatient diagnostic accounts.</li>
	<li style="text-align:justify;">Queries physicians as necessary to clarify missing, ambiguous, incomplete, or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding.</li>
	<li style="text-align:justify;">Accurately abstracts information from the medical record into the abstracting module.</li>
	<li style="text-align:justify;">Posts charges for injection and other procedure coding, as required.</li>
	<li style="text-align:justify;">Notifies Coding Manager and Manager of Revenue Cycle when the surgery order is missing, or the observation order is either missing or does not contain complaint Observation statements. </li>
	<li style="text-align:justify;">Demonstrates competencies with PC and software systems used by the Coding and HIM staff.</li>
	<li style="text-align:justify;">Manages time and workload with understanding of the relationship between coding accuracy, timeliness, and deadlines.</li>
	<li style="text-align:justify;">Keeps current of all changes in coding by reading all new Coding Clinics and CPT Assistants annually.</li>
	<li style="text-align:justify;">Complete a minimum of 10 hours of formal education and 10 hours of informal education (reading coding clinics and CPT Assistant), which can be turned to formal by taking the quiz on the back and submitting for credit.</li>
	<li style="text-align:justify;">Performs additional responsibility as directed.</li>
</ul>

&nbsp;

BEHAVIORAL STANDARDS

<ul>
	<li>Exhibit positive customer service behavior in everyday work interactions.</li>
	<li>Demonstrate a courteous and respectful attitude to internal workforce and external customers.</li>
	<li>Communicate accurately and appropriately.</li>
	<li>Handle difficult situations in a discreet and professional manner.</li>
</ul>

&nbsp;

EDUCATION/CERTIFICATION/LICENSURE: 

<ul>
	<li>Must hold an HIM credential (RHIT) or a Coding Certification from AHIMA or the AAPC. </li>
	<li style="text-align:justify;">Coding Certification from AHIMA or the AAPC preferred. </li>
</ul>

&nbsp;

POSITION QUALIFICATIONS:

<ul>
	<li>2 years of coding experience</li>
	<li>Passing score on company coding test.</li>
	<li>Possesses basic knowledge of HIM principles and department functions.</li>
	<li>Possesses strong knowledge of ICD-10CM, ICD10-PCS and CPT coding rules and conventions.</li>
	<li>Possesses a firm knowledge of medical terminology, anatomy and physiology and disease processes. </li>
	<li>Ability to analyze charts for compliant orders and performs appropriate follow-up for chart deficiencies that impact coding.</li>
	<li>Ability to abstract information from the medical record for indices and statistical reports.</li>
	<li>Excellent PC and software utilization skills.</li>
	<li>Ability to work independently.</li>
</ul>

&nbsp;

PHYSICAL REQUIREMENTS:

<ul>
	<li>To perform this job successfully, an individual must be able to perform each essential job duties satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant to be considered.</li>
	<li>This job requires visual abilities, auditory abilities, must be intact to perform duties.</li>
	<li>Must be able to perform repetitive tasks/motions.</li>
</ul>

Surg/Op Coder

Two years of coding experience; RHIT or coding certification preferred; strong ICD-10-CM/ICD-10-PCS/CPT knowledge; ability to code ED, surgery, and ancillary records; strong documentation and communication skills; independent work ethic.

Job Summary Job Summary<ul><li>Assigns appropriate codes to a limited amount of patient types.</li><li>Abstracts critical information and enters data into hospital information system.</li><li>Monitors accounts "in process" for diagnosis to assure daily DNFB standard is met.</li><li>Maintains high level of coding expertise.</li><li>Remote coding placement.</li></ul> Qualifications Qualifications<ul><li>Ability to abstract health information utilizing current coding guidelines on various patient types.</li></ul>Education<ul><li>Bachelors of Science or Associates in Applied Arts/Science or equivalent years of experience. Actively seek to obtain certification with American Health Information Management Association (AHIMA) as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS) and/or Registration with American Association of Professional Coders (AAPC) as a Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC) or other equivalent coding certification.</li></ul>Experience<ul><li>Minimum of one year of professional coding experience required.</li></ul>

RI Coder II

Coder II

One year of professional coding experience; ability to abstract health information using current coding guidelines.

Security ClearanceNot Required
 <h2>Duties</h2>*Complete all application requirements detailed in the "Required Documents" section of this announcement.* Major Duties and Responsibilities: 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management services. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, with limited guidance from higher level MRTs (Coder). Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications and procedures. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria 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. 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. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks. Work Schedule: Monday - Friday; 7:30 a.m. - 4:00 p.m. Compressed/Flexible: Not Authorized. 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) 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 currently has a Return to Office (RTO) mid-term extension (180-days). Remote work is currently authorized; however, candidates may be subject to return to office in the event policy changes or the exemption is not extended. Virtual: This is not a virtual position. Functional Statement #: 58048-A. Permanent Change of Station (PCS): Not Authorized.<h2>Requirements</h2>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. Must pass pre-employment physical examination / evaluation. 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.<h2>Qualifications</h2>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.- 1 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 - Associate's degree from an accredited college or university recognized by the U.S. DOE 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).(Copy of transcripts is required when submitting application) OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately 1 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. The sponsoring academic institution must have been accredited by a national U.S. DOE accreditor, or comparable international accrediting authority at the time the program was completed.(Copy of completed program showing required courses/classes) OR Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. 6 months of creditable experience that indicates knowledge of medical 4 terminology, general understanding of medical coding and the health record, and 1 year above high school, with a minimum of 6 semester hours of health information technology courses. 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 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).(Copy of valid transcripts required when submitting application). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have one of the below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determinations In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: GS-8 Medical Records Technician (Coder-Outpatient) Full Performance Level Experience. 1 year of creditable experience equivalent to the next lower grade level. GS- 8 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, 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 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. The ability to use judgment in completing assignments using incomplete or inadequate guidelines. This vacancy is listed at the full performance level GS -8. For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.<h2>Education</h2>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/.<h2>Other Information</h2>Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. 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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.

Medical Records Technician (Coder-Outpatient)

Medical Records Technician

Experience or education in medical terminology, anatomy, physiology, and medical coding; knowledge of ICD, CPT, HCPCS; outpatient coding scope.

Security ClearanceNot Required
 <h2>Duties</h2>*Complete all application requirements detailed in the "Required Documents" section of this announcement.* Total Rewards of a Allied Health Professional Major Duties and Responsibilities: 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Select and assign codes from current versions of ICD-10-CM, CPT, and HCPCS classification systems. Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with limited guidance from higher level MRTs (Coder). Utilize various computer applications to abstract records, assign codes, and record and transmit data. Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) for one or more specialty and subspecialty health care services provided by the VAMC. Has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD) Clinical Modification (CM), 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 (E/M) code to ensure ethical, accurate, and complete coding. Adheres 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. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing. Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts supervisor when needed. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks. Work Schedule: Monday - Friday; 7:30 a.m. - 4:00 p.m. Compressed/Flexible: Not Authorized. 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) 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 currently has a Return to Office (RTO) mid-term extension (180-days). Remote work is currently authorized; however, candidates may be subject to return to office in the event policy changes or the exemption is not extended. Virtual: This is not a virtual position. Functional Statement #: 58044-A; 58045-A; 58046-A; 58047-A; 58048-A Permanent Change of Station (PCS): Not Authorized<h2>Requirements</h2>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. Must pass pre-employment physical examination / evaluation. 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.<h2>Qualifications</h2>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.- 1 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 - Associate's degree from an accredited college or university recognized by the U.S. DOE 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 1 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. The sponsoring academic institution must have been accredited by a national U.S. DOE accreditor, or comparable international accrediting authority at the time the program was completed. OR Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. 6 months of creditable experience that indicates knowledge of medical 4 terminology, general understanding of medical coding and the health record, and 1 year above high school, with a minimum of 6 semester hours of health information technology courses. 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 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder) Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have one of the 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 (Current VHA employees only) Grade Determinations In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: GS-4 MRT(Coder-Outpatient) Experience or Education. None beyond basic requirements. GS-5 MRT(Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level OR Education. Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university recognized by the U.S. DOE, 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. GS-5 Demonstrated KSA's. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to use health information technology and software products used in MRT (Coder) positions. Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation. Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines. Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, and the ability to follow-up on pending issues. GS-6 MRT(Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level. GS-6 Demonstrated KSA's. 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 outpatient coding and evaluate the adequacy of the documentation. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. Ability to apply laws and regulations on the confidentiality of health information. Ability to accurately apply the ICD CM, PCS and CPT guidelines to coding scenarios. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation. GS-7 MRT (Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level. GS-7 Demonstrated KSA's In addition to the experience above, the candidate must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and procedures, and verifying the relationship between health record documentation and coder assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. GS-8 MRT(Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level. GS- 8 Demonstrated KSA's. 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, 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 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. The ability to use judgment in completing assignments using incomplete or inadequate guidelines. The full performance level is GS 8. The actual grade that an applicant may be selected is in the range of 4 to 8 .<h2>Education</h2>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/.<h2>Other Information</h2>For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. 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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.

Experience with medical terminology, anatomy, coding (ICD-10-CM, CPT, HCPCS); knowledge of health information management; ability to abstract records and code outpatient procedures.

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