Medical Records Technician (Coder)
Department Of Veterans Affairs - San Antonio, TX

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Vacancy Identification Number (VIN): 924222

This is a Bargaining Unit Position.

To fulfill President Lincoln's promise - "To care for him who shall have borne the battle, and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans.

How would you like to become a part of a team providing compassionate care to Veterans?

These vacancies are advertised at the range of grades covered by the VA qualifications standard.

As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries.

City of San Antonio Information: http://www.sanantonio.gov/

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 Appointing Authority. KEY REQUIREMENTS

U. S. Citizenship
Must pass pre-employment examination
English Language Proficiency required
Designated and-or Random Drug Testing required

Background and-or Security Investigation required DUTIES:
Tour of Duty: M-F 8:00 am - 4:30 pm

NOTE: 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. The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate.

The Medical Record Technician/Coder is a staff position located under the Health Information Management Section of the Medical Administration Service, South Texas Veterans Health Care System, San Antonio, Texas. This position is responsible for maintaining the quality of patient records, assigning of appropriate International Classification of Diseases Clinical Modification (ICD-9-CM), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes, and various other duties as assigned. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill.

Relocation Expenses: Relocation expenses are not authorized for this position. QUALIFICATIONS REQUIRED:

Citizenship: Citizen of the United States

English Language Proficiency: Medical Records Technician (Coder) must be
proficient in spoken and written English as required by 38 U.S.C. 7402(d), and
7407(d).
Experience: Two years of experience that demonstrates the applicant’s ability to perform the work, or provides familiarity with the work. Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT Coder work.

OR,

Education: Successful completion of an associate’s degree with a major field of study in medical record technology/health information technology which was accredited by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) 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 in this provision 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 1 year of experience.
-- Successful completion of a post-high school course of study in medical record technology, which includes courses in anatomy, physiology, and medical record techniques and procedures, may substitute on a month-for-month basis for up to 1 year of experience.

--Successful completion of post-high school courses for medical administrative personnel, obtained in a closely supervised training program given by the Armed Forces, may be substituted for experience on a month-for-month basis for up to 6 months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures.

Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

GS-4

Experience or Education: None
beyond basic requirements.

Demonstrated
Knowledge, Skills, and Abilities

1. Basic knowledge of medical
terminology;

2.
Basic knowledge of disease processes and human anatomy;

3. Basic knowledge of medical
record/health information guidelines, techniques, and procedures;

4.
Knowledge of the medical and legal significance of medical records.

GS-5

Experience: In addition to the basic
requirements, at least 1 year of experience at the next lower grade level and
must fully meet the KSAs at that level. In addition, the candidate must demonstrate

the following KSAs:
OR,

Education:
Successful completion of a
baccalaureate degree from an accredited college or university with a major
field of study in medical record technology/health information technology or a
related degree with courses related to medical record technology sufficient to
evidence the core competencies identified.

Demonstrated Knowledge, Skills, and

Abilities:
1. Ability to apply knowledge of
medical terminology, human anatomy/pathophysiology, and disease processes
sufficient to appropriately file, locate, and disclose health information;

2 . Ability to correctly apply a
practical knowledge of laws and regulations related to the confidentiality of
health information and the release of information from medical records;

3. Knowledge of the internal
organization of medical records and medical record references and procedures as
appropriate to the position;

4. Ability to use health information
software appropriate to the position, such as the electronic patient record, record
tracking systems, chart deficiency systems, coding and abstracting systems,
release of information systems, document scanning technology, electronic
spreadsheets, transcription systems, encoder products, electronic encounter
forms, database software, etc.

GS-6

Experience:
One year of experience comparable to the next lower level and must fully meet
the KSAs at that level. In addition, the candidate must demonstrate the following

KSAs:
Demonstrated

Knowledge, Skills and Abilities:
1.
Ability to apply knowledge of medical
terminology, human anatomy/pathophysiology, and disease processes to fully
understand the content of a patient record;

2.
Ability to navigate efficiently through the
paper and electronic medical record to find needed information;

3.
Skill in interpreting and adapting health
information guidelines that are not completely applicable to the work or have
gaps in specificity and ability to use judgment in completing assignments with
incomplete or inadequate guidelines;

4.
If assigned to medical record analysis,
ability to judge whether medical records contain sufficient information for
regulatory requirements; are acceptable as legal documents; are adequate for
continuity of patient care; and support education and research needs. This
includes the ability to take appropriate actions if medical record contents are
not adequate; accurate, timely, and/or reliable;

5.
Ability to apply laws and regulations on
the confidentiality of health information (e.g., Privacy Act, Freedom of Information
Act, Health Insurance Portability and Accountability Act (HIPAA);

6.
If assigned to a tumor registry position,
ability to apply guidelines and standards for the maintenance of an approved
tumor registry; and

7.
If assigned to a medical coding position, comprehensive knowledge of
classification systems, such as current versions of International
Classification of Diseases (ICD), Current Procedural Technology (CPT),the
Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure
Coding System(HCPCS), and skill in applying coding knowledge.

GS-7

Experience: One year of experience comparable to the next lower grade
level and must fully meet the KSAs at that level including those for tumor
registry or coder assignments if applicable. In addition, the

candidate must demonstrate the following KSAs:
Medical Record Technician Coding Positions: Medical coding
assignments at this grade level represent the advanced developmental level
leading to the full performance level. It is expected that the medical coder
will do more than validate code assignments made by clinical staff, but will
have the skill to make independent judgment in selection of codes based on
medical documentation and personal coding knowledge and skill. Reviewing codes
selected by physicians/ health care providers or reviewing entries on an
encounter form or superbill is not considered comprehensive coding and, without
the demonstration of additional skills, is not acceptable to achieve this
level. Since coding rules are specific to individual classification systems,
knowledge of coding systems other than the one utilized in the position for
which the individual is being boarded does not automatically meet the
requirements of the position. Generally, to receive credit for experience, the
coder should have performed the type of coding specified as a significant
portion of duties on a regular and recurring basis, and provide evidence of the
core competencies identified.

Demonstrated Knowledge, Skills and

Abilities:
1. Knowledge of classification systems,
such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying
coding knowledge to a wide range of specialty areas;

2. Knowledge of Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers
for Medicare & Medicaid Services (CMS) and/or VHA medical record
documentation requirements;

3. Ability to communicate with clinical
staff on coding and documentation issues such as recording inpatient and
outpatient diagnoses and procedures, the use of encounter forms, the correct
sequencing of diagnoses/ procedures, and/or the relationship between health
care documentation and code assignment;

4. Ability to research and solve
complex questions related to coding and documentation, such as adequate health
information documentation, coding, billing, resident supervision, etc.; and

5. Skill in reviewing and correcting
system or processing errors, reviewing transmission reports, and ensuring all
assigned episodes are complete and accurate as appropriate to the duties
assigned,

GS-8

Experience: One year of experience that equipped you with the particular
knowledge, skills, and abilities to perform the duties of this position
successfully that is equivalent to at least the GS-7 level.

Medical Record Technician (Medical Coder) Positions: This is considered to be the full performance level for this
assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:

Demonstrated Knowledge, Skills, and Abilities:
1. Ability to analyze the medical
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 medical record, the terminology, the
significance of the comments, and the disease process/pathophysiology of the
patient;

2. Skill in reviewing medical record
documentation and assigning current versions of the classification systems
required in the current position, such as ICD and CPT; and

3. Advanced knowledge of the full scope
of coding and abstracting including inpatient discharges, surgical cases,
diagnostic studies and procedures, outpatient encounters, and inpatient
professional fees for a highly diversified range of specialties and
subspecialties, such as orthopedics, neurosurgery, cardiology,
gastroenterology, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia,
acute and long term psychiatry including addiction treatment, hospice,
ambulatory surgery, and other types of care.

Creditable Experience:
Knowledge of Current Medical Record Technology: To be creditable, the experience must have required the use of knowledge, skills, abilities, and other characteristics (also referred to as “core competencies”) associated with current health information or medical record technology and/or cancer registry practice.

Quality of Experience: Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be at a level comparable to medical record technology experience at the next lower grade level.

Part-Time Experience: Part-time experience as a professional medical record technician is credited according to its relationship to a full-time workweek. For example, a medical record technician would receive 1 week of full-time credit for each 2 weeks of half-time work.

Specialized Areas for Medical Record Technicians

Medical Coders analyze and abstract medical record data and assign codes using clinical classification systems. Medical coding requires independent judgment based on medical record documentation and personal coding knowledge and skill. Certification is offered by AHIMA as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or Registered Health Information Technician (RHIT). Certification is offered by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder Apprentice (CPC-A), Certified Professional Coder-Hospital Apprentice (CPC-H-A), Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H) and is highly desired at the higher grade levels.

References:
VA Handbook 5005/15, Part II, Appendix G35 Medical Record Technician Qualification Standard GS-675 at: http://www.va.gov/ohrm/joblistings/VAQualStds.doc (also available in the local Human Resources Office)

PHYSICAL REQUIREMENTS: The work is mostly sedentary; however, walking, stair climbing, bending stooping, and carrying light weight documents, folders, and manuals are required. See VA Directive and Handbook 5019. http://www.va.gov/vapubs/viewPublication.asp?Pub_ID=229&FType=2
NOTE: If you meet the qualification requirements, you will be rated against other eligible applicants, based on your online questionnaire and supporting documents to determine if you qualify for the position, then referred to the selecting official for further review. If a panel is to be convened, Best Qualified candidates will be referred and contacted by the panel if they choose to interview. Since your rating will be based primarily on your responses, please be specific on actual duties performed or education received.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

APPLICANTS PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement.) Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

Applicants can verify accreditation at the following website: http://www.ed.gov/admins/finaid/accred/index.html All education claimed by applicants will be verified by the appointing agency accordingly.

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.

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference on the Occupational Questionnaire in the section provided and provide a legible copy of your DD214(s) Member 4 copy, showing all dates of service as well as character of service (honorable, general, etc.). Additionally, Veterans with service-connected disability of 10% or more must also submit a copy of their official statement from the Department of Veterans Affairs, or from a branch of the Armed Forces, certifying their service-connected disability and/or their receipt of compensation for service-connected disability. Veterans with service-connected disability of less than 10%, non-service-connected disability, and Purple Heart recipients, as well as those claiming derived preference for a spouse, widow or widower, or natural mother, should refer to and submit a completed SF-15, “Application for 10-Point Veteran Preference” and required documentation with your application materials. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx .

Applicants are responsible for ensuring that all relevant information regarding their qualifications is documented in the application package. Failure to provide all of the information and documentation requested may result in the applicant receiving less than full consideration in the qualification process.

INCOMPLETE APPLICATIONS will receive a rating of Ineligible due to missing forms. Requests for reconsideration of ratings will not be considered for applicants who fail to submit a complete application package. We cannot be held responsible for incompatible software or fax transmissions, etc.

HOW YOU WILL BE EVALUATED:
Once the application process is complete, a review of your application will be made to ensure you meet the job requirements. To determine if you are qualified for this job, your resume and supporting documentation will be compared against your responses to the occupational questionnaire. The numeric rating you receive is based on your responses to the questionnaire. The score is a measure of the degree to which your background matches the knowledge, skills and abilities required of this position. If, after reviewing your resume and or supporting documentation, a determination is made that you have inflated your qualifications and or experience your score can and will be adjusted to more accurately reflect your abilities. Please follow all instructions carefully. Errors or omissions may affect your rating or consideration for employment. BENEFITS:

Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, thrift savings plan, and participation in the Federal Employees Retirement System. In addition to traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life. For more information please visit us at http://www4.va.gov/JOBS/Job_Benefits/benefits.asp .

OTHER INFORMATION:
This position is in the Excepted Service and does not confer Competitive Status.

This job opportunity announcement may be used to fill additional vacancies.

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About this company
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The United States Department of Veterans Affairs (VA) is a government-run military veteran benefit system with Cabinet-level status. It is...