LEAD MEDICAL RECORDS TECHNICIAN (CODER)

We are seeking motivated and dependable Lead Medical Records Technician (Coder -Inpatient)! This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician based settings

Duties:

• Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities.
• Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources.
• Reviews compliance monitors with Supervisor and identifies training needs. Reviews, audits, trains, monitors and completes special assignments within specified time frames.
• Required to train others on the encoder product suite. Utilizes this system on an on-going basis to perform core coding duties and audits. conditions and resource needs.
• Has constant interaction with health care providers evaluating and communicating with the expectation on improving health record documentation which will result in improved patient care and improved revenue Detroit VAMC,FS# 94382-A Page 4 of 5 generation.
• Identifies the principal diagnosis and principal procedure for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and procedure codes are selected from the current version of the ICD coding system.
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and PCS 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, 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.

Total Rewards of a Allied Health Professional

Work Schedule: Monday - Friday, 8:00 AM - 4:30 PM EST. This position requires the candidate to work in the Eastern Time Zone (ET) and maintain a standard business day schedule. All work, meetings, and collaboration must be conducted during these hours. Candidates must be available to respond to work-related communications and participate in scheduled activities within this time frame.
Recruitment Incentive (Sign-on Bonus): Not Authorized
Permanent Change of Station (Relocation Assistance): Not Authorized
Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Telework: This position is currently authorized for telework - Location negotiable, incumbent must live within 50 mile radius of a VA Medical Center to meet the Return to Office Executive Order requirements, selected candidates may be required to Return to Office. This will be discussed during the interview process.
Remote/Virtual: This position is currently 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.
Virtual: This is not a virtual position.
Functional Statement #: 94382A
Relocation/Recruitment Incentives: Not Authorized.

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 (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. §7403(f).
• 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 towards meeting basic experience requirements. The following experience and 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.
  2. Mastery Level Certification through AHIMA or AAPC.
  3. Clinical Documentation Improvement Certification through AHIMA or ACDIS.

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: GS-09 Lead Medical Records Technician (Coder)

Experience: One year of creditable experience equivalent to the journey grade level MRT (Coder). This experience may include, but is not limited to: select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected, when necessary. Correct any identified data errors or inconsistencies. Ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data.

Knowledge, Skills, and Abilities (KSAs): In addition to the experience described 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 begin assigned 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.

Certification. Employees at this level must have a current/valid/unexpired Mastery Level Certification through AAPC, AHIMA or ACDIS.

• 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 Master 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).

Preferred Experience: Preferred candidates will have a minimum of five or more years of direct coding experience. Experience in billing is not considered "equivalent".

References: VA Handbook 5005/122, Part II, Appendix G57

The full performance level of this vacancy is GS-09.

Physical Requirements: Work is mostly sedentary. However, there will be some periods of walking, bending, lifting or carrying or work-related items. Normal safety precautions and practices are required for working in a healthcare environment.

If you are basing your qualifications on education (or a combination of education and experience) or if the position requires a college education to qualify, you must submit a copy of your transcripts with your application. Your official or unofficial transcript must reflect: name of the college or university, full address of the college or university, your name, class title(s) with the number of credits earned/completed, the degree received, if applicable, and date degree conferred. A copy of your certificate/degree or screenshot of your current classes are not a replacement of your transcript and they will not be used in the qualifying process.

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/.

• 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.
• 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.
• Loss of Credential. 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.

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.