Medical Records Technician (Coder-Outpatient)
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. 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. Insures provider documentation is complete and supports the diagnoses and procedures coded. 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. 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. Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate. 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, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Work Schedule:
Monday - Friday, 8:
00 AM - 4:
30 PM Virtual:
Available for highly qualified applicants. Financial Disclosure Report:
Not required Basic Requirements:
United States Citizenship:
Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g. 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 record. 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; OR Experience/Education Combination:
Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and
Experience:
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 health record techniques and procedures. Also requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Six months of creditable experience that indicates knowledge of medical terminology and general understanding of medical coding and the health record and one year above high school with a minimum of 6 semester hours of health information technology courses. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC.(2) Mastery Level Certification through AHIMA or AAPC.(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS English Language Proficiency:
MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). Grade Determinations:
In addition to the basic requirements for employment, the following criteria must be met. GS-04:
Experience or Education. None beyond basic requirements. GS-05:
Experience:
One year (1) of experience equivalent to the next lower grade level (GS-04) OR 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. 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. Examples of experience include but not limited to:
Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. GS-06:
Experience:
At least one (1) year of experience equivalent to the next lower grade level (GS-05). Examples of experience include but not limited to:
Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. GS-07:
Experience. At least one (1) year of experience equivalent to the next lower grade level (GS-06). Examples of experience include but not limited to:
Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. They utilize various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. GS-08:
Experience:
At least one (1) year of experience equivalent to the next lower grade level (GS-07). Examples of experience include but not limited to:
Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. They review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. MRTs in this assignment also query clinical staff with documentation requirements to support the coding process. They use various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. Additionally, you will be rated on the Knowledge, Skills, and Abilities (KSA's):
Please make sure that each is addressed in your application package. Please refer to Appendix G57 for KSA's in the reference below. References:
VA Regulations, specifically VA Handbook 5005, Part II Appendix G57, MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARD. 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). Preferred
Experience:
Certified Professional Coder 2 years minimum of experience in Inpatient/Outpatient setting Extensive knowledge and skills in the use of different types of software applications which include but are not limited to; word processing, spreadsheet and data base software for data validation programs The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8. Physical Requirements:
Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; Both hands required; hearing (aid permitted); Hearing without aid; and sitting for up to 8 hours; Repetitive motion for computer data entry.
Estimated Salary: $20 to $28 per hour based on qualifications.
Monday - Friday, 8:
00 AM - 4:
30 PM Virtual:
Available for highly qualified applicants. Financial Disclosure Report:
Not required Basic Requirements:
United States Citizenship:
Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g. 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 record. 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; OR Experience/Education Combination:
Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and
Experience:
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 health record techniques and procedures. Also requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Six months of creditable experience that indicates knowledge of medical terminology and general understanding of medical coding and the health record and one year above high school with a minimum of 6 semester hours of health information technology courses. Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC.(2) Mastery Level Certification through AHIMA or AAPC.(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS English Language Proficiency:
MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). Grade Determinations:
In addition to the basic requirements for employment, the following criteria must be met. GS-04:
Experience or Education. None beyond basic requirements. GS-05:
Experience:
One year (1) of experience equivalent to the next lower grade level (GS-04) OR 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. 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. Examples of experience include but not limited to:
Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. GS-06:
Experience:
At least one (1) year of experience equivalent to the next lower grade level (GS-05). Examples of experience include but not limited to:
Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. GS-07:
Experience. At least one (1) year of experience equivalent to the next lower grade level (GS-06). Examples of experience include but not limited to:
Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. They utilize various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. GS-08:
Experience:
At least one (1) year of experience equivalent to the next lower grade level (GS-07). Examples of experience include but not limited to:
Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. They review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. MRTs in this assignment also query clinical staff with documentation requirements to support the coding process. They use various computer applications to abstract records, assign codes, and record and transmit data. They also ensure audit findings have been corrected and refiled. For full qualification standard please reference the VA Handbook 5005, Part II Appendix G57, Medical Record Technician Qualification Standard below. Additionally, you will be rated on the Knowledge, Skills, and Abilities (KSA's):
Please make sure that each is addressed in your application package. Please refer to Appendix G57 for KSA's in the reference below. References:
VA Regulations, specifically VA Handbook 5005, Part II Appendix G57, MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARD. 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). Preferred
Experience:
Certified Professional Coder 2 years minimum of experience in Inpatient/Outpatient setting Extensive knowledge and skills in the use of different types of software applications which include but are not limited to; word processing, spreadsheet and data base software for data validation programs The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8. Physical Requirements:
Light lifting (under 15 pounds); light carrying (under 15 pounds); use of fingers; Both hands required; hearing (aid permitted); Hearing without aid; and sitting for up to 8 hours; Repetitive motion for computer data entry.
- Department:
0675 Medical Records Technician - Salary Range:
$31,208 to $62,269 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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