Summary This position is in the Health Information Management Section at the VA Northern California Health Care System. Certified Coders classify medical data from patient health records. Seeking candidates with robust inpatient coding experience for a complex, multi-specialty Acute Care Hospital. Expertise in ICU coding, psychiatric inpatient admissions, complex surgical procedures using ICD10-PCS and DRG assignment is required. Experience in high volume, tertiary, or academic hospitals is preferred. Responsibilities Duties include but are not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Comprehensive review of inpatient documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures using ICD-PCS for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. Independently review and abstract clinical data from the inpatient record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. Consult directly with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data 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 accurately reflect services rendered. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected; correct any identified data errors or inconsistencies. Maintain a 95% coding accuracy on quality audits. Ensure audit findings have been corrected and refiled. Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, or ancillary code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Use various required computer applications to abstract records, assign codes, and record and transmit data. Work Schedule: Monday - Friday, 8:00am - 4:30pm PST Virtual: This position is Remote 100% Functional Statement #: 07110F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a trial period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be 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 state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). 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. Qualifications 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: 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 (ROI) work. OR 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 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. Certification Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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: Medical Records Technician (Coder-Inpatient), GS-04 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Inpatient), GS-05 Experience. One year of creditable experience equivalent to the next lower grade level; OR Education. Successful completion of a bachelor'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 management or a related degree with a minimum of 24 semester hours in health information management or technology. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.). Ability to navigate through and abstract pertinent information from health records. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient records based on health record documentation. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. Ability to manage priorities and coordinate work to complete duties within required timeframes and the ability to follow-up on pending issues. Medical Records Technician (Coder-Inpatient), GS-06 Experience. One year of creditable experience equivalent to the next lower grade level. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA). Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). Medical Records Technician (Coder-Inpatient), GS-07 Experience. One year of creditable experience equivalent to the next lower grade level. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment. Ability to research and solve coding and documentation related issues. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG. Medical Records Technician (Coder-Inpatient), GS-08 Experience: One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation. 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/pathophysiology of the patient. Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or in adequate guidelines. Education Preferred Experience: Minimum of 2 years, full time, inpatient hospital coding experience. Coding for a highly complex, multi-specialty, Acute care hospital which includes coding intensive care unit stays, psychiatric inpatient stays, and inpatient surgical (PCS) coding. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy ranges from GS-04 to GS-08. Physical Requirements: VA Directive and Handbook 5019, Employee Occupational Health Service. IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (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 rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application 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 application for this announcement, nor does it guarantee further consideration 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 status. VA encourages persons with disabilities to apply. The health-related 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 alternate 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 tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.