"Alerted.org

Summary The VISN 19 Consolidated Coding Unit Lead is located within the Business Office Support Services, Health Information Management section, within VISN 19k. MRTs are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, multi-specialty clinics, and specialty centers. NOTE: The 2-page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below. Responsibilities Major duties include but are not limited to: Assigns codes to documented patient care encounters (inpatient and/or outpatient) covering the full range of health care services provided by the VAMC. 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. 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. 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. 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. Makes recommendations to supervisor concerning disciplinary actions due to insufficient performance, and identifies continuing education needs. Required to train others on the encoder product suite. Utilizes this system on an ongoing basis to perform core coding duties and audits. Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided. Work Schedule: Monday through Friday, 8:00am - 430pm Remote: Yes. This position is eligible for Remote work and is exempted from return to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status. Functional Statement #: 53490-O Relocation/Recruitment Incentives: Not authorized Financial Disclosure Report: Not required 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. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. 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). You may be required to serve a trial period. The first year of continuous service in the same or similar position of a preference eligible in the excepted service is a trial period. The first two years of continuous service in the same or similar position of an individual in the excepted service, other than a preference eligible, is a trial period. At least 60 days prior to the end of each employee's initial trial period, management officials shall, to the extent practicable, meet to discuss the employee's performance and conduct (based in part on input from the employee's supervisor), the needs of the agency, and whether their continued employment would advance the public interest, the organizational goals of the agency, and the efficiency of the service. Within 30 days prior to the end of each employee's trial period, management officials shall determine whether to finalize the employee's appointment to the Federal service, or whether to terminate their service. Before the employee is terminated, they shall be notified in writing of the effective date of the action. Qualifications To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 11/07/2025. 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 experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR, Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records). OR, Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience: Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses. OR, 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Grade Determinations. In addition to the basic requirements, candidates must possess one year of experience equivalent to the next lower grade level (GS-08). Experience should demonstrate the ability to analyze medical records to identify all pertinent diagnoses and procedures for coding; the ability to accurately perform the full scope of outpatient and inpatient coding, skill in interpreting and adapting health information guidelines; and the ability to use judgment in completing assignments using incomplete or inadequate guidelines. Note: To be creditable experience must have demonstrated the use of knowledge, skills, and abilities associated with current health information or health record technology and/or cancer registry practice and must be directly related to the position to be filled or in a related field. Demonstrated KSAs. In addition to the experience above, candidates must possess the following Knowledge Skills and Abilities (KSAs): Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities of a medical record function 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.; Comprehensive knowledge of medical record technology theories, methods, procedures, and techniques for assigned areas; AND Ability to communicate tactfully and effectively, both orally and in writing, in order to meet program objectives. This may include preparing reports in various formats and presenting data to various organizational levels. 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. References: VA Handbook 5005 Part II Appendix G35. Physical Requirements: This position involves primarily sedentary work. Education There is no education substitution for experience for the GS-09 pay grade. Additional Information This job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. This position is in the Excepted Service and does not confer competitive status. This position is eligible for Remote work and is exempted from return to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status. Selectees will work 100% of the time in a non-VA owned space outside or inside of the local commuting area of parent station. The employee's workspace must be suitable for conducting business, remote employees are expected to provide a secure, distraction-free home-based worksite with reliable high speed internet connectivity. The employee will be required to travel to the closest VA Medical Center or VA Outpatient Clinic for issuance of equipment, and as needed for technical support. Selectees will be required to self-certify that their remote workplace meets all safety, privacy, and internet speed requirements. This position may fall under the Presidential Memorandum titled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved when it's up for review.