Medical Record Technician (Coder) CDIS Job in Lebanon, Pennsylvania – Department of Veterans Affairs



The United States government is a massive employer, and is always looking for qualified candidates to fill a wide variety of open employment positions in locations across the country. Below you’ll find a Qualification Summary for an active, open job listing from the Department of Veterans Affairs. The opening is for a Medical Record Technician (Coder) CDIS in Lebanon, Pennsylvania Feel free to browse this and any other job listings and reach out to us with any questions!

Medical Record Technician (Coder) CDIS – Lebanon, Pennsylvania
Veterans Affairs, Veterans Health Administration, Department of Veterans Affairs
Job ID: 51695
Start Date: 02/14/2019
End Date: 02/26/2019

Qualification Summary
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/26/2019. 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. Language: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d). 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); 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; or (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 additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. Preferred Experience: Must have six years of direct specialized hands-on inpatient and outpatient medical coding experience; Coding credentials such as Registered Health Information Technologist, Registered Health Information Administrator, Certified Coding Specialist, Certified Coding Specialist – Professional, and Certified Professional Coder; Course work in medical terminology, anatomy and physiology, and exposure to pharmacology; Ability to code inpatient and outpatient diagnoses, surgeries and procedures utilizing ICD-10-CM, CPT and HCPCS coding systems. Ability to apply modifiers as appropriate. Thorough understanding of ICD-10 Offical Coding Guidelines. Understanding of medical necessity requirements; Understanding of expanded Provider documentation requirements for ICD-10; Experience in Evaluation and Management Coding for professional services. Grade Determinations:
Note: Qualified applicants need to demonstrate a minimum of 6 years of coding experience. Medical billing experience is not creditable experience. Experience: One year of experience equivalent to the next lower grade level (GS-8) and examples of experience are but are not limited to:
perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties; inpatient duties consist of the
performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid
conditions, surgery, and procedures; outpatient duties consist of the performance of a comprehensive review of documentation within the
health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and
management services; directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the
health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters
and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies. In addition to experience incumbents and must fully meet the KSAs at the GS-8 level:
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. In addition to meeting the experience and KSA’s mentioned above the candidate must demonstrate the following KSAs at the GS-9:
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
2. Ability to interpret and analyze all information in a patient’s health record, including laboratory and other test results, to identify opportunities
for more precise and/or complete documentation in the health record;
3. Knowledge of anatomy and physiology, pathophysiology, and pharmacology;
4. Ability to establish and maintain strong verbal and written communication with providers;
5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines;
6. Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators;
7. Knowledge of severity of illness and risk of mortality indicators; and
8. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions
may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. References: VA Handbook 5005/79, Part II, Appendix G35. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-9. Physical Requirements: Work is primarily sedentary. Required walking, bending and carrying of light loads, standing and sitting for long

If you’d like to submit a resume or apply for this position, please contact Premier Veterans at All are free to apply!


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