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Job Title: Medical Record Technician (Coder)
Company Name: Veterans Affairs, Veterans Health Administration
Location: Sioux Falls, SD
Position Type: Full Time
Post Date: 10/01/2017
Expire Date: 11/30/2017
Job Categories: Computers, Software, Customer Service and Call Center, Healthcare, Other, Healthcare, Practitioner and Technician, Human Resources, Information Technology, Insurance, Internet/E-Commerce, Executive Management, Research & Development, Medical, Web Technology, Nonprofit and Volunteer Services
Job Description
Medical Record Technician (Coder)

The Sioux Falls VA Health Care System is currently recruiting for a Full-time, Permanent, Medical Record Technician (Coder). This position will be located in the Health Administration Service Line. As a Medical Record Technician (Coder), you are responsible for the following duties to include, but not limited to:

    • Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
    • Selects and assigns codes from the current version of one or more coding systems to include the International Classification of Diseases-Clinical Modification (ICD-9/10-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding Systems HCPCS.
    • 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 record.
    • Searches the patient 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.
    • Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in within established timelines.
    • Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
    • Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.
    • Monitors ever-changing regulatory and policy requirements affecting coded information.
    • Complies with coding changes crucial to the accuracy of the facility database as well as all cost recovery 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.

Work Schedule: The tour of duty for this position is typically Monday-Friday, Administrative Days. The employee must residewithin the Sioux Falls, SD commuting area (approximately 50 miles) and will be required to be on site at the Sioux Falls, SD Duty Station no less than one day per week.

Functional Statement Title: Medical Records Technician (Coder)

Basic Requirements:

  • U.S. Citizenship. Non-Citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
  • 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).(Transcripts Required).OR
  • Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
    (a) 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.(Transcripts Required)
    (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 medical record techniques and procedures. Also requires six additionalmonths of experience that indicates knowledge of medical terminology and general understanding of the health record.(Transcripts Required)
  • Must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Preferred Certifications include one or more of the following:

Certified Professional Coder (CPC)
Certified Professional Coder-Payer (CPC-P)
Certified Professional Medical Auditor (CPMA)
Registered Health Information Technician (RHIT)
Certified Coding Specialist (CCS)
Certified Coding Specialist- Physician-based(CCS-P)


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.

Grade Determinations:

GS-4 MRT (Coder) - Entry Level

Experience or Education. None beyond basic requirements.

GS-5 MRT (Coder) Developmental Level 1

Experience. One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.);
2. Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and
3. Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues.

GS-6 MRT (Coder) Developmental Level 2

Experience. One year of experience equivalent to the next lower level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to navigate through health records to find needed information;
2. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines;
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and
4. Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation.

GS-7 MRT (Coder) Developmental Level 3

Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record;
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment;
3. Ability to research and solve coding and documentation related issues; and
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

GS-8 MRT (Coder) Full Performance Level

Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;
2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and
3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

References: VA Handbook 5005/79 PT II, Appendix G-35 dated Sept. 5, 2014. This can be found in the local Human Resources Office.

Physical Requirements: Daily intermittent walking, standing, bending, stooping, reaching, and carrying of lightweight items required. Rigid deadlines and need for high degree of accuracy periodically becomes stressful.

To apply for this position, you must provide a complete application package which includes the following REQUIRED material listed below:

  1. Complete and current professional resume or CV.
  2. VA Form 10-2850c - Application forAssociated HealthOccupations.Available at the VA Forms website: http://www.va.gov/vaforms/search_action.asp?FormNo=10-2850&tkey=&Action=Search.
  3. Responses to the Occupational Questionnaire. (Listed within the Application Manager program when you click on the "Apply Online" button).
  4. Please use the checklist to ensure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), documentation to support Veterans Preference claims, etc. You will not be contacted for additional information.

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), or 10pt (CP/CPS, XPP, XP), or for Sole Survivor Preference (SSP), on the Occupational Questionnaire in the section(s) provided. A legible copy of your DD214(s) indicating character of service, disability certification, SF-15 (if claiming 10 pt. preference) or if you are currently serving on active duty and expected to be released or discharged within 120 days; documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), or dates of impending separation. Documentation is required for eligibility verification.
Faxing Applications or Supporting Documents: You are encouraged to apply online. Applying online will allow you to review and track the status of your application. If you are unable to apply online or unable to upload your supporting documents to your online application, follow the directions located at the following site: Fax Options. The Vacancy ID of the job opportunity announcement is 2011319.
NOTE: If you applied online and your application is complete, do not fax the paper application (1203-FX) as this will overwrite your prior online responses and may result in you being found ineligible.

Qualifications & Requirements

Basic Requirements:

  • U.S. Citizenship. Non-Citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
  • 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).(Transcripts Required).OR
  • Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
    (a) 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.(Transcripts Required)
    (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 medical record techniques and procedures. Also requires six additionalmonths of experience that indicates knowledge of medical terminology and general understanding of the health record.(Transcripts Required)
  • Must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).

Preferred Certifications include one or more of the following:

Certified Professional Coder (CPC)
Certified Professional Coder-Payer (CPC-P)
Certified Professional Medical Auditor (CPMA)
Registered Health Information Technician (RHIT)
Certified Coding Specialist (CCS)
Certified Coding Specialist- Physician-based(CCS-P)


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.

Grade Determinations:

GS-4 MRT (Coder) - Entry Level

Experience or Education. None beyond basic requirements.

GS-5 MRT (Coder) Developmental Level 1

Experience. One year of experience equivalent to the next lower grade level or successful completion of four years of education above high school from an accredited college or university with a minimum of 24 semester hours in health information technology.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.);
2. Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and
3. Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues.

GS-6 MRT (Coder) Developmental Level 2

Experience. One year of experience equivalent to the next lower level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to navigate through health records to find needed information;
2. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and ability to use judgment in completing assignments with incomplete or inadequate guidelines;
3. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and
4. Comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and skill in applying said classifications based on health record documentation.

GS-7 MRT (Coder) Developmental Level 3

Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Skill in applying current coding classifications to a variety of specialty care areas to accurately reflect service and care provided based on documentation in the health record;
2. Ability to communicate with clinical staff for specific coding and documentation issues such as recording inpatient and/or outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health care documentation and code assignment;
3. Ability to research and solve coding and documentation related issues; and
4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.

GS-8 MRT (Coder) Full Performance Level

Experience. One year of experience equivalent to the next lower grade level.
Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;
2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and
3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

References: VA Handbook 5005/79 PT II, Appendix G-35 dated Sept. 5, 2014. This can be found in the local Human Resources Office.

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Contact Information
Contact Name:
Company Name: Veterans Affairs, Veterans Health Administration
Phone Number:
Fax Number:
Contact Email:BRITTNEY.HENDRY@VA.GOV
Website:http://www.ecentralmetrics.com/url/?u=77978741318%2D272&r=http%3A%2F%2Fwww%2Evacareers%2Eva%2Egov%2Fjob%2Dsearch%2Fjob%2Ddetail%2Easp%3Fjob%3D287132
Company Description:

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