Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• Experience and Education: (1) Experience
• One year of creditable experience that indicates knowledge of medical terminology and general understanding of health records
• Six months of the required one year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT work
• OR, (2) Education
• An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, legal aspects of health care, and introduction to health records)
• OR, (3) Experience/Education Combination
• Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements
• The following experience and educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management courses
• (b) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and 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
• The training program may be substituted on a month for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures
• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria)
• Grade Determinations: Lead Medical Records Technician (Coder), GS-9 Experience
• One year of creditable experience equivalent to the journey grade level MRT (Coder) Certification
• Employees at this level must have a mastery level certification
• 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 at least 25% of the time
• Lead MRTs (Coder) must be able to perform all duties of a MRT (Coder)
• Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy
• provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations
• initiate, prepare, and maintain various reports, and analyze data
• and may also coordinate, assign, and monitor workflow
• They provide input for performance evaluations and hiring
• They orient and instruct new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software
• They ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection
• They monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs
• They develop coding training materials and present a curriculum encompassing ongoing training initiatives
• They provide assistance with coding inquiries from providers, MRTs (Coder), billers, and other facility staff
• Lead MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area
• Lead MRTs (Coder) may be at a facility or in a consolidated coding unit (CCU)
• Demonstrated Knowledge, Skills, and Abilities
• In addition to the experience above, the candidate must demonstrate all of the following KSAs: i
• Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc
• ii
• Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner
• V iii
• Ability to effectively communicate, both orally and in writing, in order to meet program objectives
• iv
• Knowledge of training methods and the ability to provide training to new coding staff
• v
• Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels
• vi
• Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff
• Mastery Level Certification
• This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC
• To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation
• Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications
• Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies
• However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC)
• Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/
• The actual grade at which an applicant may be selected for this vacancy is GS-9 grade level
• Physical Requirements: See VA Directive and Handbook 5019.