Medical Records Technician (Coder-Outpatient and Inpatient) Position Available In Columbia, Florida

Medical Records Technician (Coder-Outpient and Inpient) Department of Veterans Affairs Veterans Health Administrion Veterans Health Administrion Summary The position is aligned under the Health Informion Management Section (HIMS) of Medical Administrion Service (MAS) with North Florida/South Georgia Veterans Health System (NF/SG VHS); Lake City VA Medical Center. The Medical Record Technician (MRT/Coder) is responsible for performing a quality review of pient care documents and assigning codes specific to care provided. Overview Accepting applicions Open & closing des 05/23/2025 to 06/03/2025 Salary $39,276

• $78,372 per year Pay scale & grade GS 4
• 8 Locion 1 vacancy in the following locion: Lake City, FL Remote job No Telework eligible No Travel Required 50% or less
• You may be expected to travel for this position.

Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential 8 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

CBTC-12736454-25-DC

Control number 837574800 This job is open to Internal to an agency Current federal employees of the hiring agency th posted the job announcement. Clarificion from the agency

THIS VACANCY IS OPEN TO CURRENT PERMANENT EMPLOYEES OF THE U. S. DEPARTMENT OF VETERANS AFFAIRS

(VA

NATIONWIDE

) ONLY. Videos Duties The Medical Records Technician (Coder-In/Outpient), duties include but are not limited to: Perform the full scope of inpient and outpient coding duties. 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. 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. 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. Directly consult with the clinical staff for clarificion of conflicting, incomplete, or ambiguous clinical da in the health record. Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurely reflect services rendered. Review provider health record documention to ensure th it supports diagnostic and procedural codes assigned; and is consistent with required medical coding nomenclure. Query clinical staff with documention requirements to support the coding process. Enter and correct informion th has been rejected, when necessary. Correct any identified da errors or inconsistencies. Ensure audit findings have been corrected and refiled. 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.

Work Schedule :

Monday to Friday, 8:00am to 4:30pm

Telework :

Not Available Virtual:

This is not a virtual position

Relocion/Recruitment Incentives :

Not Authorized Permanent Change of Stion (PCS): Not Authorized Fi nancial

Disclosure Report:

Not required 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. Must pass pre-employment physical examinion. 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.

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 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). Certificion. Persons hired or reassigned t o 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. 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 :

In addition to meeting the basic requirements sted above, the following qualificions criteria must be met in determining the approprie grade assignment of candides. Medical Records Technician (Coder-Outpient and Inpient) Medical Records Technician, GS-4 (a) Experience or Educion. None beyond basic requirements. Medical Records Technician (Coder-Outpient and Inpient), GS-5 (a) Experience. One year of creditable experience equivalent to the next lower grade level; OR, (b) Educion. Successful completion of a bachelor’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 management, or a reled degree with a minimum of 24 semester hours in health informion management or technology. Medical Records Technician (Coder-Outpient and Inpient), GS-6/7/8 (a) Experience. One year of creditable experience equivalent to the next lower grade level. You must be able to demonstre th you possess the (below) competencies which are necessary to perform the work of the position. Please ensure your resume/CV/applicion contains sufficient informion to support the level of experience/educion/training; otherwise, we will not be able to award you credit for the experience/educion/training you claim. These are the KSA’s for this subject position: GS-05 1. Ability to use health informion technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.). 2. Ability to navige through and abstract pertinent informion from health records. 3. Knowledge of the

ICD CM, PCS

Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. 4. Ability to apply knowledge of medical terminology, human anomy/physiology, and disease processes to accurely assign codes to inpient and outpient episodes of care based on health record documention. GS-06 1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evalue the adequacy of the documention. 2. Ability to determine whether health records contain sufficient informion for regulory requirements, are acceptable as legal documents, and support the assigned codes. 3. Ability to apply laws and regulions on the confidentiality of health informion (e.g., Privacy Act, Freedom of Informion Act, and HIPAA) 4. Ability to accurely apply the

ICD CM, PCS

Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. 5. Comprehensive knowledge of current classificion systems ICD CM, PCS, CPT, HCPCS, and skill in applying classificions to both GS-07 1. Skill in applying current coding classificions to a variety of inpient and outpient specialty care areas to accurely reflect service and care provided based on documention in the health record. 2. Ability to communice with clinical staff for specific coding and documention issues, such as recording inpient and outpient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relionship between health record documention and code assignment. 3. Ability to research and solve coding and documention reled issues. GS-08 1. 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. 2. 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. 3. Skill in interpreting and adapting health informion guidelines th are not 19 completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadeque guidelines.

References:

please . The full performance level of this vacancy is GS-08. The actual grade which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08.

Physical Requirements:

See handbook 5005

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 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. Area of Considerion

• Eligible applicions reviewed and referred in the following order: 1.

Current permanent VA employees of the facility. 2.All other VA employees. 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 SF-50/ Notificion of Personnel Action Certificion(s)
• AHIMA, AAPC, or

ACDIS CERTIFICATION

(please see above qualificion requirements) 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 Transcript 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 06/03/2025 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 David Califano Phone Address Malcom Randall Department of Veterans Affairs Medical Center 1601 Southwest Archer Road Gainesville, FL 32608 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 SF-50/ Notificion of Personnel Action Certificion(s)

• AHIMA, AAPC, or

ACDIS CERTIFICATION

(please see above qualificion requirements) 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 Transcript 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 06/03/2025 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 David Califano Phone Address Malcom Randall Department of Veterans Affairs Medical Center 1601 Southwest Archer Road Gainesville, FL 32608 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 05/23/2025 to 06/03/2025 Salary $39,276

• $78,372 per year Pay scale & grade GS 4
• 8 Locion 1 vacancy in the following locion: Lake City, FL Remote job No Telework eligible No Travel Required 50% or less
• You may be expected to travel for this position.

Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential 8 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

CBTC-12736454-25-DC

Control number 837574800 ., .