Amended Lead Medical Records Technician (Coder-Outpatient)

Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate prepare and maintain various reports and analyze data; and may also coordinate assign and monitor workflow.

Duties include but are not limited to:

• Provide input for performance evaluations and hiring.
• Orient and instruct new coding personnel and/or students on coding abstracting and use of the electronic health record and encoder software.
• Ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection.
• Monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs.
• Develop coding training materials and present a curriculum encompassing ongoing training initiatives.
• Provide assistance with coding inquiries from providers MRTs (Coder) billers and other facility staff.
• Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities.
• Instructs employees in specific tasks and job techniques and makes available written instructions reference materials and supplies.
• Gives on the job training to new coders and students to provide the individual with the basic knowledge skill and ability to perform the full range of routine and non-routine responsibilities required.
• Trains and works closely with professional and administrative staff to assist in the development maintenance and usage of ICD and CPT codes to ensure accurate data capture.
• Distributes and balance the workload among employees in accordance with established workflow or job specialization assures timely accomplishment of the assigned workload.

Work Schedule: Monday - Friday 0800-1630
Telework: Available.
Virtual: This is not a virtual position.
Functional Statement #: 82644F

• You must be a U.S. Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• 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 identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation/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.

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 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.

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 and Education-Documentation Submitted.
  • 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. 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
• 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:
  • 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.
  • 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:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • NOTE-Documentation Submitted: Mastery level certification is required for all positions above the journey level; however for clinical documentation improvement specialist assignments a clinical documentation improvement certification may be substituted for a mastery level certification.
  • NOTE: Following initial certification credentials must be maintained through rigorous continuing education ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation which may result in termination of employment. At the discretion of the appointing official an employee may be reassigned to another occupation for which he/she qualifies if a placement opportunity exists.

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).

Grade Determinations:

• Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder).
• Certification. Employees at this level must have a mastery level certification. 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).
• Demonstrated Knowledge Skills and Abilities. In addition to the experience above the candidate must demonstrate all of the following KSAs:
  • Ability to work with a team to provide technical guidance plan organize and coordinate activities in order to effectively complete job duties of assignment such as distributing workload monitoring the status and progress of work monitoring accuracy of work etc.
  • Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient inpatient outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  • Ability to effectively communicate both orally and in writing in order to meet program objectives.
  • Knowledge of training methods and the ability to provide training to new coding staff.
  • Ability to collect and analyze data and present results in various formats which may include presenting reports to various organizational levels.
  • Leadership skills including interpersonal relations and conflict resolution between employees managers and clinical staff.

Reference: For more information on this qualification standard please visit Requirements: The work is mostly sedentary; however some bending stretching walking and lifting are required.