About the role
Summary
This position is in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center located in Milwaukee, Wisconsin. 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.
Major duties
This position is located in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Major Duties: Advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (CD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). 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. 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. 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. Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. Work Schedule: Monday - Friday 8:00am - 4:30pm Compressed/Flexible: No available Telework: Yes Functional Statement #: 10480F Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. PCS Appraised Value Offer (AVO): Not authorized.
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 U.S. Citizenship: Must be a 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.) English Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). 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); (TRANSCRIPTS REQUIRED) 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-0675series 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. IN ADDITION TO MEETING THE BASIC REQUIREMENTS LISTED ABOVE, YOU MUST MEET THE FOLLOWING GRADE REQUIREMENTS. GS-9 Grade Requirements Certification. Must have a mastery level certification. Experience. Must have One year of creditable experience equivalent to the GS-8 grade level MRT (Coder). Experience includes: performing all duties of a MRT (Coder) which includes: select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. 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. 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. 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. In addition candidates 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. The full performance level of this vacancy is GS-9. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. The work does not require any special physical effort or ability.
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. Must pass pre-employment physical evaluation. 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.
