MEDICAL RECORDS TECHNICIAN (CODER) Auditor Position Available In Charleston, South Carolina

MEDICAL RECORDS TECHNICIAN

(CODER) Auditor Department of Veterans Affairs Veterans Health Administrion Ralph H. Johnson VA Medical Center Summary The Medical Records Technician (Coder) is responsible for abstracting medical record da and assigning codes using current clinical classificion systems approprie for the type of care provided. This position is loced in the Health Informion Management Services (HIMS) section within the Health Administrion Service the Ralph H. Johnson VA Medical Center. Overview Accepting applicions Open & closing des 06/13/2025 to 07/03/2025 Salary $62,474 – $81,214 per year Pay scale & grade GS 9 Locion 1 vacancy in the following locion: North Charleston, SC 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 9 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-12749867-25-MG

Control number 838796900 This job is open to The public U.S. Citizens, Nionals or those who owe allegiance to the U.S. Federal employees – Excepted service Current federal employees whose agencies have their own hiring rules, pay scales and evaluion criteria. Internal to an agency Current federal employees of the hiring agency th posted the job announcement. Clarificion from the agency This announcement is open to current, permanent VA employees and open to the Public.

Videos Duties Basic Duties:

Auditors serve as experts of current coding conventions and regulions reled to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. Provide recommendions on approprie coding and are responsible for maintaining current knowledge of the various regulory guidelines and requirements. Auditors work with staff to ensure th regulions are met, or areas of weakness are identified and reported to approprie supervisor for corrective action. Perform prospective coding audits and utilize results to identify processing inadequacies and re-educe coding staff where necessary. Coordine retrospective reviews to ensure adeque auditing of coding activities. Act independently to plan, organize, direct and control areas with emphasis on da validion, analysis and generion of reports associed with the Medical Center’s health informion management program. This includes managing the professional health informion management functions such as retrieving, reviewing and abstracting health record informion. Determine quality control measures needed; initie and implement them by use of monitors and/or continuous review. Applies comprehensive knowledge of medical terminology, anomy & physiology, disease processes, trement modalities, diagnostic tests, medicions, procedures as well as the principles and practices of health services and the organizional structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the Internional Classificion 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 approprie diagnosis, operion, procedure, ancillary, or Evaluion and Management code to ensure ethical, accure, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpient and outpient settings) used to classify pients under the Veterans Equitable Resource Allocion (VERA) program th cegorizes all VA pients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulory and policy requirements affecting coded informion for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility dabase as well as all cost recovery programs. Assists facility staff with documention requirements to completely and accurely reflect the pient care provided; provides technical support in the areas of regulions and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclure, and proper sequencing. Directly consults with the professional staff for clarificion of conflicting or ambiguous clinical da. Expertly searches the pient record to find documention justifying code assignment based on an expanded knowledge of the organizion and structure of the pient health record. Uses a variety of windows-based applicions in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applicions (VistA and CPRS) as well as the encoder product suite. Ensures current versions of all software applicions are loaded and functional after any updes or changes, Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding. Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulions; inities various reports and analyze da. Facilites improved overall quality, completeness and accuracy of coded da. Ensures the accuracy and completeness of clinical informion used for measuring and reporting physician and medical center outcomes with continuing educion to all members of the pient care team on an ongoing basis. Responsible for performing audits of coded da, developing criteria, collecting da, graphing and analyzing results, creing reports and communicing in writing and/or in person to approprie leadership and groups.

Work Schedule :

Monday – Friday, 8:00-4:30pm

Telework :

As determined by the agency policy.

Virtual:

This is not a virtual position. Functional Stement # : 534-10650

F 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. 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 :

a) Auditor assignments can be established for any of the coder subspecialties (outpient, inpient, or outpient and inpient combined). The subspecialty reflected in the title, e.g., MRT (Coder) Auditor (Outpient). (b) Experience . One year of creditable experience equivalent to the journey grade level of a MRT (Coder). (c) Certificion . Employees this level must have a mastery level certificion Assignment . For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent least 25% of the time. Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines reled to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilite improved overall quality, completeness, and accuracy of coded da. They provide recommendions on approprie coding and are responsible for maintaining current knowledge of the various regulory guidelines and requirements. They assist facility staff with documention requirements to completely and accurely reflect the pient care provided. They provide technical support in the areas of regulions and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclure, and proper sequencing. They directly consult with the clinical staff for clarificion of conflicting or ambiguous clinical da. They use computer applicions with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. They perform prospective and retrospective coding audits and use results to identify documention, coding inadequacies, and re-educe clinical and coding staff based on audit results. They act independently to plan, organize, and perform auditing with emphasis on da validion, analysis, and generion of reports. They assist in the development of guidelines for da quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrive da. They ensure th all coded da is fully documented and supported. They maintain stistical dabase(s) to track the results and valide the program. They identify pterns and variions in coding practices with regular reports to the medical staff and management. Demonstred Knowledge, Skills, and Abilities. In addition to the experience above, the candide must demonstre all of the following

KSAs:

i. Advanced knowledge of current coding classificion systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpient, inpient, outpient and inpient combined). ii. Ability to research and solve complex questions reled to coding conventions and guidelines in an accure and timely manner. iii. Ability to review coded da and supporting documention to identify adherence to applicable standards, coding conventions and guidelines, and documention requirements. iv. Ability to form and present audit results, identify trends, and provide guidance to improve accuracy. v. Skill in interpersonal relions and conflict resolution to deal with individuals all organizional levels.

Grade Determinions :

In addition to meeting the Basic Requirements, the grade specific requirements and Knowledge, Skills and Abilities (KSAs) must be met as listed below as specified each grade level.

Reference:

Former VA handbook reference: PART II Appendix G57 effective de December 10, 2019 The full performance level of this vacancy is GS-8. The actual grade which an applicant may be selected for this vacancy is GS9.

Physical Requirements:

Physical aspects associed with work required of this assignment are typical for the occupion and would generally not require a pre-placement examinion. Educion

IMPORTANT

A transcript must be submitted with your applicion if you are basing all or part of your qualificions on 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. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be against

COVID-19

subject to such accommodions as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locions. If selected, you required to be fully vaccined against COVID-19 and submit documention of proof of vaccinion before your start de. The agency will provide additional informion regarding wh informion or documention needed and how you can request a legally required accommodion from this requirement using the reasonable accommodion process. 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 use this to 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 (Schedule A) Disability Letter (VA) License Other (1) PCS Orders Performance Appraisal Professional Certificion Resume Separion Notice (RIF) SF-15 SF-50/ Notificion of Personnel Action Transcript 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 07/03/2025 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. To verify your applicion is complete, log into your

USA JOBS

account, , select the Applicion Stus link and then select the more informion link for this position. The Details page will display the stus of your applicion, the documention received and processed, and any correspondence the agency has sent reled to this applicion. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete applicion, log into your

USA JOBS

account and click Upde Applicion in the vacancy announcement. You must re-select your resume and/or other documents from your

USA JOBS

account or your applicion incomplete. Agency contact informion Myceria Gardner Phone Address Ralph H Johnson Department of Veterans Affairs Medical Center 109 Bee Street Charleston, SC 29401 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 use this to 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 (Schedule A) Disability Letter (VA) License Other (1) PCS Orders Performance Appraisal Professional Certificion Resume Separion Notice (RIF) SF-15 SF-50/ Notificion of Personnel Action Transcript 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 07/03/2025 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. To verify your applicion is complete, log into your

USA JOBS

account, , select the Applicion Stus link and then select the more informion link for this position. The Details page will display the stus of your applicion, the documention received and processed, and any correspondence the agency has sent reled to this applicion. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete applicion, log into your

USA JOBS

account and click Upde Applicion in the vacancy announcement. You must re-select your resume and/or other documents from your

USA JOBS

account or your applicion incomplete. Agency contact informion Myceria Gardner Phone Address Ralph H Johnson Department of Veterans Affairs Medical Center 109 Bee Street Charleston, SC 29401 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 06/13/2025 to 07/03/2025 Salary $62,474 – $81,214 per year Pay scale & grade GS 9 Locion 1 vacancy in the following locion: North Charleston, SC 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 9 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-12749867-25-MG

Control number 838796900 ., .