Medical Records Technician
Department of Veterans Affairs - Dallas, TX

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Vacancy Identification Number (VIN): 582198 (Please include on all documents)

Our mission: 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.


Special Employment Consideration: Individuals eligible for the following appointments are encouraged to apply: 5 CFR 213.3102 "u", Schedule A, Appointment of persons with disabilities ; mental retardation, severe physical disabilities, or psychiatric disabilities; and Disabled veterans with a compensable service-connected disability of 30% or more.


You must be a US citizen to apply for this job.

Subject to a background/suitability investigation.

Designated and/or random drug testing may be required.

Must pass pre-employment examination.

English Language Proficiency required.

This position is located in the Health Information Management Service (HIMS) at the VA North Texas Health Care System (VANTHCS). The incumbent is responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided. Codes all inpatient stays (facility and professional fees), all write-in diagnoses and procedures for outpatient encounters and laboratory, radiology, pathology surgical and outpatient encounters that are billed to insurance companies. Captures data through Ambulatory Care Data Capture Superbill form (both printed and electronic), electronic visit notes, Quadramed/DSS Complaint Coding Module (CCM) and Patient Treatment File (PTF) in VISTA and in Quadramed/DSS. Converts narrative electronic visit notes to ICD-9-CM, CPT-4 and HCPCS codes. Abstracts diagnoses, procedures performed, level of patient evaluation, drugs injected, etc. for all inpatient stays and outpatient encounters. Reviews records thoroughly for documentation of final diagnosis and procedures, complications and co-morbid conditions. Insures physician documentation supports the diagnoses and procedures coded. Completes PTF in Quadramed and VISTA by abstracting information from the record. Reviews entire patient record in order to submit most accurate information and assign precise codes. Inputs information in the Quadramed/DSS PTF and VISTA PTF computer systems for transmission to Austin. Performs corrective actions in response to edit analysis listing. Codes information from patient medical records to generate a clinical care patient care database for the Medical Center. Codes Agent Orange/Persian Gulf exams, Fee Basis and Contract Nursing Home encounters. Manages workflow to ensure required time frames are met.

Duty Hours: Monday - Friday 8:00 am-4:30 pm

Grade and salary to be determined by the Medical Records Technician Professional Standards Board.

Relocation expenses and/or incentives are not authorized.

VA Handbook 5005/15, Part II, Appendix G35, MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARD, dated March 17, 2006, .


A. Citizenship. Citizen of the United States.

B. Experience and Education

(1) 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 work.


(2) 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) at the time the program was completed.


(3) 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:

(a) Successful completion of an associate's degree in a field of study other than medical records/health information will substitute for 18 months of the required experience.

(b) 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.

(c) 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.

(d) 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.

C . Physical Requirements. A physical will be required for this position.

D. English Language Proficiency. MRTs must be proficient in spoken and written English.

SPECIALIZED EXPERIENCE: One year of experience comparable to the next lower grade level for the appropriate assignment area and must fully meet the KSAs at that level. Examples of qualifying specialized experience include: organize, process, maintain, compile and extract medical record and health data; assign codes using clinical classification systems; check medical records for completeness, accuracy, and compliance with requirements of regulatory and accrediting agencies.

GS-6: 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. 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).

5. 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-07: 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.

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-08: 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.

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.

CERTIFICATION: 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.

Applicants must successfully complete VETPRO VA credentials databank if selected.


All requirements must be met by the closing date of the vacancy announcement.

This position will be filled on a full-time permanent basis. Upon completing any required probationary period, the position will be permanent.


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: 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 their application or résumé. Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must complete an SF 15, Application for 10-Point Veteran Preference. Veterans who are still in the service may be granted tentative preference on the basis of information contained in their applications, but they must produce a DD Form 214 or other proof prior to appointment to document entitlement to preference. For more information on Veterans' Preference, please visit .

Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. You may also be evaluated based upon the question responses you provide during a structured interview. In responding to structured interview questions you should be sure to cite specific examples of experience, explain exactly what you did, and the outcome.

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, 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 .


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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...