Lead Medical Records Technician (Coder-Inpatient)

Summary

The Dayton VAMC is recruiting for a Lead Medical Records Coder. Lead MRTs Coder must be able to perform all duties of a MRT Coder. 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

Duties Include, but are not limited to: Assigns codes to documented patient care encounters (inpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. 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. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs. 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. 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. Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines. Distributes and balance the workload among employees in accordance with established workflow or job specialization, assures timely accomplishment of the assigned workload. All other duties as assigned. Work Schedule: 0800-1630, Monday-Friday Telework: This is a fully remote position. This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order. Virtual: This is not a virtual position. Functional Statement #: 929620 Requirements

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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. 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 interest. In 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. 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. 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 records. 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 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: Mastery Level Certification through AHIMA or AAPC. 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: Lead Medical Records Technician (Coder), GS-9 (a) Lead coder assignments can be established for any of the coder subspecialties (outpatient, inpatient, outpatient and inpatient combined). The subspecialty will be reflected in the title, e.g., Lead MRT (Coder-Outpatient). (b) Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder). (c) Certification. Employees at this level must have a mastery level certification. (d) Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Lead MRTs (Coder) must be able to perform all duties of a MRT (Coder). 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. They provide input for performance evaluations and hiring. They orient and instruct new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software. They ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection. They monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs. They develop coding training materials and present a curriculum encompassing ongoing training initiatives. They provide assistance with coding inquiries from providers, MRTs (Coder), billers, and other facility staff. Lead MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Lead MRTs (Coder) may be at a facility or in a consolidated coding unit (CCU). (e) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. 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. ii. 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. iii. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. iv. Knowledge of training methods and the ability to provide training to new coding staff. v. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. vi. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. 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 comments, 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 inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. 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. Preferred Experience: 4 years minimum of Medical Records Coding Experience. Mastery level certification is required. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-9. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9 to GS-9. Physical Requirements: See VA Handbook 5019

Education

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: http://ope.ed.gov/accreditation/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. How You Will Be Evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members. Other 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 applicant's 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. VA Healthcare System Serving Ohio, Indiana and Michigan (VISN 10) advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being." The Dayton, Ohio VA & its CBOC's are committed to hiring a diverse workforce from various backgrounds and individuals who demonstrate a diversity, equity and inclusion-related mindset and behaviors. We are strongly seeking candidates who represent the full range of cultural and identity factors including but not limited to race, ethnicity, sex, sexual orientation/identity, gender identity and expression, age, language, abilities/disabilities, socioeconomic status, religion, spiritual practices, geographic region, and other characteristics.