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Supervisory Medical Records Technician(Coder)
- Veterans Affairs, Veterans Health Administration (Las Vegas, NV)
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Summary This position is located in the Health Information Management (HIM) section at the Southern Nevada Healthcare System VA Medical Center. MRTs Coder are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis/procedure. Responsibilities Major duties and responsibilities include but are not limited to the following: Supervisory MRTs (Coder)are responsible for supervising coding staff at the facility level. Supervisory MRTs (Coder) must be able to perform all duties of a MRT (Coder). The supervisory coder is responsible for the supervision, administrative management, and direction of coding staff. Perform a full range of supervisory responsibilities, to include evaluating the performance of subordinate staff, approving sick and annual leave requests, identifying educational or training needs, resolving employee complaints, and taking disciplinary actions, when necessary. Inform higher level management of anticipated vacancies or increases in workload. Serve as an expert coding resource to ensure accuracy and integrity of all coding. Collaborate with revenue, compliance, and other departments to support coding accuracy that is consistent with the official guidelines for coding and reporting. Ensures claim denials related to coding errors are resolved, and/or daily coding rejects are corrected for accurate billing and data collection. Collect and prepare data for studies involving inpatient stays and outpatient encounters for clinical evaluation purposes, prepare and maintain a variety of complex records and daily, monthly, or "on demand" reports, as requested. Creates and monitors outpatient reports, inpatient case mix reports, top DRGs, and key performance indicators to identify patterns, trends, and variations. Investigate and evaluate potential causes for changes or problems and collaborate with the appropriate staff to effect resolution or explain variances. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. 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. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Develops performance standards and conducts performance evaluations for subordinate staff. Interviews new employees, recommends selection, and carries out training and development of reassignments, awards or disciplinary action. Schedules the sequence of work and operations on a weekly, monthly and quarterly basis to assure even workflow and distribution, expeditious handling of priorities and the meeting of deadlines. Prepares workload and production reports; reports on operations and problems encountered; and presents proposed requests for resource needs based on past experience, anticipated staffing, equipment, and space. Formulates and issues written instructions and procedures and special instructions for non-routine or complex assignments or to clarify published guides. Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data; and coordinates, assigns, and monitors the workflow. Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. 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. 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 subordinates and identifies training needs. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs on unit operations, coding, abstracting, and use of an electronic medical record. Directly responsible to the Assistant Chief or Chief of Health Information Management, who gives general guidance. Exercises independent judgment in carrying out duties and responsibilities and has complete limited authority to plan, design and direct. Work Schedule: Monday to Friday 0730am-1600pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements 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. You may be required to serve a probationary period. 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 dentification 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). Qualifications Basic Requirements: Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) Experience and Education (1) 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, (2) 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, (3) 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, (4) 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 4 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. NOTE: 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. Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. (3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation. (5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT. English Language Proficiency. MRTs Coder must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Grade Determinations: For GS-10 Experience. One year of creditable experience equivalent to the next lower grade level. Certification. Employees at this level must have a mastery level certification. In addition to the basic requirements you must demonstrate that you possess one year of specialized experience at the next lower grade level (GS-09). Example of GS 09 specialized experiences include but not limited to the following: i. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). ii. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. iii. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. iv. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. v. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels AND Must demonstrate the Knowledge, Skills, and Abilities based on your application for this position: Please make sure that each is addressed in detail in the body of your resume. i. Ability to perform a full range of supervisory duties, to include recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure duties are completed in an accurate and timely fashion. ii. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). iii. Ability to provide or coordinate staff development and training. iv. Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers. v. Ability to collect and analyze data, identify trends, and present results in various formats. The full performance level of this vacancy is GS-10. The actual grade at which an applicant may be selected for this vacancy is GS-10. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: The work is primarily sedentary. However, there may be some walking, standing, bending, carrying of light items such as papers, books, small parts, etc. Light carrying (15-44 pounds); pushing (4 hours); reaching above shoulder; use of fingers; walking (1-4 hours); standing (1-4 hours); repeating bending.. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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/. Additional Information Receiving Service Credit or 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. 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.
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