Medical Records Technician (Coder-Outpatient)
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Job Location:
San Antonio, TX - USA
Yearly Salary:
$ 56703 - 73711
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
Summary
Performs independent inpatient and outpatient medical coding by reviewing full electronic and paper records to assign accurate ICD CPT and HCPCS codes. Abstracts clinical demographic and utilization data to support workload reporting billing reimbursement and compliance. Validates documentation resolves ambiguities with providers updates data systems meets closeout deadlines and provides guidance to improve documentation quality and data integrity.
Conditions of employment
- 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 ( Effective May 7 2025 drivers licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- Must pass pre-employment physical examination.
- 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.
- 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.
Qualifications
Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.
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 or 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 records. OR
- Education:
- A) An associates 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
- B) 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 creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
- A) Six months of creditable experience that indicates knowledge of medical terminology 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.
- 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 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).
- 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.
- Apprentice/Associate Level Certification. This is considered an entry level coding certification and is limited to certification obtained through the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC). To be acceptable for qualifications the specific certification must represent a comprehensive competency in coding across a wide range of services. Stand-alone specialty certifications do not meet the definition of apprentice/associate level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of apprentice/associate level certification may be added/removed by the above certifying bodies. However current apprentice/associate level certifications include: Certified Coding Associate (CCA) Certified Professional Coder-Apprentice (CPC-A) and Certified Outpatient Coding-Apprentice (COC-A).
- (2) Mastery Level Certification through AHIMA or AAPC.
- This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However current mastery level certifications include: Certified Coding Specialist (CCS) Certified Coding Specialist - Physician-based (CCS-P)Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Professional Coder (CPC) Certified Outpatient Coder(COC) Certified Inpatient Coder (CIC).
- (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
- This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). (SEE CONTINUATION IN EDUCATION SECTION)
- (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
Grade Determination.
Medical Records Technician (Coder-Outpatient) GS-08:
- Experience: One year of creditable experience equivalent to the next lower grade level including: reviewing record documentation to abstract all required medical and administrative data with minimal guidance from higher level MRTs (Coder); reviewing and abstracting clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; reviewing provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature; and use of various computer applications to abstract records assign codes and record and transmit data. AND
- Demonstrated Knowledge Skills and Abilities (KSAs): In addition to the experience above the candidate must demonstrate all of the following KSAs:
- Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record the terminology the significance of the findings and the disease process/pathophysiology of the patient.
- Ability to accurately perform the full scope of outpatient coding including ambulatory surgical cases diagnostic studies and procedures and outpatient encounters and/or inpatient professional fee services coding.
- Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
Reference: For more information on this qualification standard please visit Requirements:
- Light carrying under 15-pounds Use of fingers Use of computer screen Ability to distinguish basic colors Hearing (aid may be permitted) Ability to communicate with patients and staff
Education
(CONTINUED FROM QUALIFICATIONS SECTION)
Clinical Documentation Improvement Certification through AHIMA or ACDIS.
- This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications the specific certification must certify mastery in clinical documentation. Certification titles may change and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist(CCDS).
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: 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: If your school has changed names or is no longer in existence you must provide this information in your application.
Additional information
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 applicants 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.
Candidates should be committed to improving the efficiency of the Federal government passionate about the ideals of our American republic and committed to upholding the rule of law and the United States Constitution.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
Required Experience:
IC
