Medical Records Tech (Inpatient/Outpatient Coder) Position Available In Fulton, Georgia

Medical Records Tech (Inpient/Outpient Coder) Department of Veterans Affairs Veterans Health Administrion Veterans Health Administrion, VISN 07 Southeast Network, Cleland VAMC Summary Primary Purpose of the

Position:

Responsible for the assignment of approprie codes to reflect the trement provided to pients this Medical Center. This medical center is large and complex and provides hospital based and clinic based outpient services, acute medical, medical subspecialties, surgical, surgical subspecialties, psychiric care, physical rehabilition, substance abuse care as well as research and development services. Overview Accepting applicions Open & closing des 06/18/2025 to 07/07/2025 Salary $58,509 – $76,068 per year Pay scale & grade GS 8 Locion 1 vacancy in the following locion: Atlanta, GA 1 vacancy Remote job No Telework eligible Yes—as determined by the agency policy. Travel Required Not required Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential None Job family (Series) Supervisory stus No Security clearance Drug test No Position sensitivity and risk Trust determinion process Financial disclosure Bargaining unit stus Announcement number

CBTB-12745089-25-MAA

Control number 839053700 This job is open to The public U.S. Citizens, Nionals or those who owe allegiance to the U.S. Internal to an agency Current federal employees of the hiring agency th posted the job announcement. Videos Duties Captures da through the Ambulory Care Da Capture Superbill Form (both printed and electronic), electronic notes, the Quadra-med/DSS Complaint Coding Module (CCM), Pient Care encounter (PCE) and the Pient Trement File (PTF) in Vista and in Quadra-med/DSS. Convert narrive electronic notes to ICD-10-CM/PCS, CPT-4 and HCPCS codes. Manually code from the medical record documention and enter into the approprie software packages. Inpient da is captured by the Coders reading the electronic and paper medical record then converting the narrive to ICD-10-CM/PCS, CPT-4 and HCPCS codes. Valide da for accuracy of performance measurement, pient care, billing accuracy, reimbursement and research. Timely and accure coding purpose of (diagnoses), services provided, practitioner, and other case mix da for all ambulory and inpient encounters. Maintain a control system to ensure comprehensive submission of all codes for the care provided into the Pient Care Encounter (PCE), Automed Informion Capture System (AICS), Pient Trement File (PTF), Appointment Management, Surgery Package and other applicable programs in VISTA. The ICD-10-CM/PCS, CPT-4 and HCPCS codes are upded bi-annually and annually and Medical Record Technicians must be knowledgeable in the changes. Insures physician documention supports the diagnoses and procedures coded. Reviews the pient record. Provide technical advice to the professional staff. Assist professional staff in diagnostic/procedural sequencing. Complete Pient Trement File (PTF), in Quadra-med and Vista by abstracting informion, including clinical and demographic informion, from the record. The entire pient record must be reviewed. Input informion in the Quadra-med/DSS PTF and

VISTA PTF

computer systems for transmission to Austin. Perform corrective actions in response to PTF edit analysis listing for resubmitting to the Austin Automion Center. Responsible for retrospective as well as con-current coding. Codes diagnoses, operions and procedures (inpient and outpient), which requires knowledge in a variety of coding systems, using the Internional Classificion of Diseases, Ninth Revision, Clinical Modificion (ICD-10-CM/PCS), Current Procedural Terminology (CPT-4) and HCPCS Level II Code Book (HCPCS) ensuring completeness and conformance to accepted VA directives, JCAHO requirements, ICD-910 CM/PCS coding conventions and guidelines for optimal Diagnostic Reled Group (DRG) assignment. Codes informion from the pient medical record to genere a clinical care pient dabase for the Medical Center. Reviews and screens the entire medical record to abstract medical, surgical, laborory, pharmaceutical, demographic, social and administrive da from the medical record in a timely manner. Ensure th all diagnoses and procedures th may impact the facility’s reimbursement are identified and documented by the physician, sequenced correctly and coded in an accure and ethical manner for optimum reimbursement. Determine correct codes for routine, and/or new and unusual diagnoses and procedures not clearly listed in ICD-10-CM/PCS and CPT. Responsible for coding inpient and Contract Nursing Home (CNH) quarterly Census and Monthly Closeout th, VHA Headquarters directive mandes. Knowledgeable of the Ambulory Payment Classificions (APCs) and Diagnostic Reled Group (DRG). Accure and complete coding remains the primary responsibility of the MRT. Correct identificion and coding of the principal diagnosis will determine the proper Diagnostic Reled Group (DRG) for dabase and reimbursement. Assists physician, ancillary, administrive personnel and other clinical staff and ward clerks with concurrent documention requirements in compliance with coding guidelines. Code third-party billing cases as a priority. Perform quantitive/qualitive analysis of outpient/inpient medical records. Provides assistance and guidance to clinicians. Required to organize and tend least monthly in-service training sessions on coding and compliance issues and on technology advances. Perform quarterly quantitive analysis. Notify MACPAC on any coding changes th occur after the bill has been printed. Assists in completion of coding and da review for the quarterly pient census and other special surveys as manded. Provides da analysis services and performs periodic da validion reviews of documention and coding accuracy with recommendions to the lead, supervisor and Da Analyst relive to case mix reimbursement and performance measures. Performs other reled record reviews and coding as requested and assigned by the lead or supervisor.

Work Schedule :

Monday – Friday, 8:00 a.m. – 4:30 p.m.

Telework :

Available.

Virtual:

This is not a virtual position. Functional Stement # : 59004

F Relocion/Recruitment Incentives :

Not Authorized. Permanent Change of Stion (PCS): Not Authorized. Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registrion is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a probionary period. Subject to background/security investigion. Selected applicants required to complete an online onboarding process. Acceptable form(s) of identificion 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 ste-issued dentificion cards th are not REAL ID compliant cannot be utilized as an acceptable form of identificion for employment. Participion in the seasonal influenza vaccinion program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Qualificions Applicants pending the completion of educional or certificion/licensure requirements may be referred and tentively selected but may not be hired until all requirements are met.

Basic Requirements :

United Stes Citizenship:

Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

BASIC REQUIREMENTS.

a. Citizenship. Citizen of the United Stes. (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.) b. Experience and Educion (1) Experience. One year of creditable experience th indices knowledge of medical terminology, anomy, physiology, phophysiology, medical coding, and the structure and form of a health records. OR, (2) Educion. An associe’s degree from an accredited college or university recognized by the U.S. Department of Educion with a major field of study in health informion technology/health informion management, or a reled degree with a minimum of 12 semester hours in health informion technology/health informion management (e.g., courses in medical terminology, anomy 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 approximely one year or more th included courses in anomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certificion/certificion examinion, and the sponsoring academic institution must have been accredited by a nional U.S. Department of Educion accreditor, or comparable internional accrediting authority the time the program was completed; OR, (4) Experience/Educion Combinion. Equivalent combinions of creditable experience and educion are qualifying for meeting the basic requirements. The following educional/training substitutions are approprie for combining educion and creditable experience: (a) Six months of creditable experience th indices 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 informion 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 anomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience th is paid or non-paid employment equivalent to a MRT (Coder). c. Certificion. 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/Associe Level Certificion through AHIMA or AAPC. (2) Mastery Level Certificion through AHIMA or AAPC. (3) Clinical Documention Improvement Certificion through AHIMA or

ACDIS. NOTE

Mastery level certificion is required for all positions above the journey level; however, for clinical documention improvement specialist assignments, a clinical documention improvement certificion may be substituted for a mastery level certificion. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupional Health Service. g. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f) May qualify based on being covered by the Grandfhering Provision as described in the VA Qualificion Standard for this occupion (only applicable to current VHA employees who are in this occupion and meet the criteria).

Grade Determinions :

Medical Records Technician (Coder-Outpient and Inpient), GS-8 (a) Experience. One year of creditable experience equivalent to the next lower grade level. (b) Assignment. This is the journey level for this assignment. MRTs (Coder) this level perform the full scope of inpient and outpient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classificion systems to both inpient and outpient records. Inpient duties consist of the performance of a comprehensive review of documention within the health record to assign ICD CM and PCS codes for diagnosis, complicions/major complicions, comorbid/major comorbid conditions, surgery, and procedures for accure assignment of DRGs. Outpient duties consist of the performance of a comprehensive review of documention within the health record to accurely assign ICD CM codes for diagnosis and complicions, and

CPT/HCPCS

codes for surgeries, procedures, evaluion and management services, and inpient professional services. They independently review and abstract clinical da from the record for documention of diagnoses and procedures to ensure it is adeque and approprie to support the assigned codes. They code all compliced and complex medical/specialty diseases processes, pient injuries, and all medical procedures in a wide range of ambulory/inpient settings and specialties. They directly consult with the clinical staff for clarificion of conflicting, incomplete, or ambiguous clinical da in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-reled DRG, support medical necessity, resolve encoder edits, and ensure codes accurely reflect services rendered. They review provider health record documention to ensure th it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclure. They query clinical staff with documention requirements to support the coding process. They enter and correct informion th has been rejected, when necessary. They correct any identified da errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applicions to abstract records, assign codes, and record and transmit da. MRTs (Coder) may be assigned to a single facility or region, such as a consolided coding unit. (c) Demonstred Knowledge, Skills, and Abilities. In addition to the experience above, the candide must demonstre all of the following

KSAs:

i. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evalue the adequacy of the documention. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/phophysiology of the pient. ii. Ability to accurely perform the full scope of outpient coding, including ambulory surgical cases, diagnostic studies and procedures, and outpient encounters, and inpient facility coding, including inpient discharges, surgical cases, diagnostic studies and procedures, and inpient professional services. iii. Skill in interpreting and adapting health informion guidelines th are not

Preferred Experience:

Reference:

For more informion on this qualificion standard, please . The full performance level of this vacancy is 08. The actual grade which an applicant may be selected for this vacancy is in the 08.

Physical Requirements:

See VA Directive and Handbook 5019.

Educion Note:

Only educion or degrees recognized by the U.S. Department of Educion from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your educion here: . If you are using foreign educion to meet qualificion requirements, you must send a Certifice of Foreign Equivalency with your transcript in order to receive credit for th educion. For further informion, : . Additional informion Receiving Service Credit or Earning Annual (Vacion)

Leave:

Federal Employees earn annual leave a re (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 re which they earn annual leave. Such credit must be requested and approved prior to the appointment de and is not guaranteed. During the applicion process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your applicion for this announcement, nor does it guarantee further considerion for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive stus. VA encourages persons with disabilities to apply. The health-reled 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 alterne 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 tentive job offer. For more informion about the Act and the complaint process, . Benefits A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits th are designed to make your federal career very rewarding. Opens in a new window . Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more informion on the specific benefits offered. How You Will Be Evalued You evalued for this job based on how well you meet the qualificions above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your applicion, resume, C.V., and/or supporting documention verified. Please follow all instructions carefully. Errors or omissions may affect considerion for employment. Experience refers to paid and unpaid experience, including volunteer work done through Nional Service programs (e.g., Peace Corps, AmeriCorps) and other organizions (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 th transles directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify informion provided by a candide (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candide’s abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those th have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members :

Please the site for career-search tools for Veterans seeking employment VA, career development services for our existing Veterans, and coaching and reintegrion support for military service members. Benefits A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits th are designed to make your federal career very rewarding. Opens in a new window . Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more informion on the specific benefits offered. Required Documents As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have – whether you’re a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you’re eligible under their policies. To apply for this position, you must provide a complete Applicion Package which includes: Resume The following documents are accepted, and may be required if applicable to your eligibility and/or qualificions for this position. Please ensure you have included all documents required for your applicion, such as a copy of your transcript (if using educion to qualify), SF-50’s (current/former Federal employees), etc. Cover Letter DD-214/ Stement of Service Disability Letter (VA) License PCS Orders Performance Appraisal Professional Certificion Resume Separion Notice (RIF) SF-15 SF-50/

Notificion of Personnel Action Transcript Veterans’ Preference:

When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows des and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documention reled to your active duty service which reflects the des of service, character of service (honorable, general, etc.), and des of impending separion. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 “Applicion for 10 Point Veteran Preference” with required proof as sted on the form. Documention is required to award preference. For more informion on Veterans’ Preference, please . Veterans’ preference does not apply for internal or other current permanent Federal agency employees. If you are relying on your educion to meet qualificion requirements: Educion must be accredited by an accrediting institution recognized by the U.S. Department of Educion in order for it to be credited towards qualificions. Therefore, provide only the tendance and/or degrees from . Failure to provide all of the required informion as sted in this vacancy announcement may result in an ineligible ring or may affect the overall ring. How to Apply All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documention specified in the Required Documents section below. The complete applicion package must be submitted by 11:59 PM (ET) on 07/07/2025 to receive considerion. To preview the questionnaire click . To begin, click Apply Online to cree a USAJOBS account or log in to your existing account. Follow the prompts to select your

USA JOBS

resume and/or other supporting documents and complete the occupional questionnaire. Click Submit My Answers to submit your applicion package.

NOTE:

It is your responsibility to ensure your responses and approprie documention is submitted prior to the closing de. Agency contact informion Manuel Argumedo Phone Address Atlanta VA Medical Center 1670 Clairmont Road Decur, GA 30033 US Next steps Once your online applicion is submitted you will receive a confirmion notificion by email. After we receive applicion packages (including all required documents) and the vacancy announcement closes, we will review applicions to ensure qualificion and eligibility requirements are met. After the review is complete, a referral certifice(s) is issued and applicants notified of their stus by email. Referred applicants notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notificion once a selection decision has been made. You may check the stus of your applicion any time by logging into your USA Jobs account and clicking on Applicions. Informion regarding your applicion stus can be found in the .

NOTE:

Participion in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement th all HCP to receive annual seasonal influenza vaccinion or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccinion has been granted. HCP in violion of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locions or who come into contact with VA pients or other HCP as part of their duties. VHA locions include, but are not limited to, VA hospitals and associed clinics, community living centers (CLCs), community-based outpient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrive, remote and onsite, paid and without compension, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with pients outside VA medical facilities. Fair and Transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance. Required Documents To apply for this position, you must provide a complete Applicion Package which includes: Resume The following documents are accepted, and may be required if applicable to your eligibility and/or qualificions for this position. Please ensure you have included all documents required for your applicion, such as a copy of your transcript (if using educion to qualify), SF-50’s (current/former Federal employees), etc. Cover Letter DD-214/ Stement of Service Disability Letter (VA) License PCS Orders Performance Appraisal Professional Certificion Resume Separion Notice (RIF) SF-15 SF-50/

Notificion of Personnel Action Transcript Veterans’ Preference:

When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows des and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documention reled to your active duty service which reflects the des of service, character of service (honorable, general, etc.), and des of impending separion. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 “Applicion for 10 Point Veteran Preference” with required proof as sted on the form. Documention is required to award preference. For more informion on Veterans’ Preference, please . Veterans’ preference does not apply for internal or other current permanent Federal agency employees. If you are relying on your educion to meet qualificion requirements: Educion must be accredited by an accrediting institution recognized by the U.S. Department of Educion in order for it to be credited towards qualificions. Therefore, provide only the tendance and/or degrees from . Failure to provide all of the required informion as sted in this vacancy announcement may result in an ineligible ring or may affect the overall ring. How to Apply All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documention specified in the Required Documents section below. The complete applicion package must be submitted by 11:59 PM (ET) on 07/07/2025 to receive considerion. To preview the questionnaire click . To begin, click Apply Online to cree a USAJOBS account or log in to your existing account. Follow the prompts to select your

USA JOBS

resume and/or other supporting documents and complete the occupional questionnaire. Click Submit My Answers to submit your applicion package.

NOTE:

It is your responsibility to ensure your responses and approprie documention is submitted prior to the closing de. Agency contact informion Manuel Argumedo Phone Address Atlanta VA Medical Center 1670 Clairmont Road Decur, GA 30033 US Next steps Once your online applicion is submitted you will receive a confirmion notificion by email. After we receive applicion packages (including all required documents) and the vacancy announcement closes, we will review applicions to ensure qualificion and eligibility requirements are met. After the review is complete, a referral certifice(s) is issued and applicants notified of their stus by email. Referred applicants notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notificion once a selection decision has been made. You may check the stus of your applicion any time by logging into your USA Jobs account and clicking on Applicions. Informion regarding your applicion stus can be found in the .

NOTE:

Participion in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement th all HCP to receive annual seasonal influenza vaccinion or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccinion has been granted. HCP in violion of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locions or who come into contact with VA pients or other HCP as part of their duties. VHA locions include, but are not limited to, VA hospitals and associed clinics, community living centers (CLCs), community-based outpient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrive, remote and onsite, paid and without compension, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with pients outside VA medical facilities. Fair & Transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance. Overview Accepting applicions Open & closing des 06/18/2025 to 07/07/2025 Salary $58,509 – $76,068 per year Pay scale & grade GS 8 Locion 1 vacancy in the following locion: Atlanta, GA 1 vacancy Remote job No Telework eligible Yes—as determined by the agency policy. Travel Required Not required Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential None Job family (Series) Supervisory stus No Security clearance Drug test No Position sensitivity and risk Trust determinion process Financial disclosure Bargaining unit stus Announcement number

CBTB-12745089-25-MAA

Control number 839053700 ., .