Veterans Affairs, Veterans Health Administration
1 vacancy in the following location:
  • Augusta, ME
Work Schedule is Full Time - Excepted Service Permanent

Opened Friday 9/30/2016 (24 day(s) ago)

** Closes Monday 10/24/2016 (0 day(s) away)

Job Overview

Vacancy Identification Number (VIN): 1814350

OUR MISSION:To fulfill President Lincoln's promise – "To care for him who shall have borne the battle, and for his widow, and his orphan" – by serving and honoring the men and women who are America's Veterans.

How would you like to become a part of a team providing compassionate care to Veterans?

The VA Maine Healthcare System is seeking one (1) Lead Medical Records Technician (Medical Coder) to maintain the quality of patient records by assigning appropriate International Classification of Diseases Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPT-4), and Healthcare Common Procedure Coding System (HCPCS) codes for the Business Service Line. We are an employer of choice that is the center of excellence in patient care, education, and research. We value Integrity, Commitment, Advocacy, Respect, and Excellence. We value you!

As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities and leadership positions at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the Nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries. VA professionals feel good about their careers and their ability to balance work and home life. VA offers generous paid time off and a variety of predictable and flexible scheduling opportunities. For more information on the Department of Veterans Affairs, go to

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.

Recruitment incentives may be authorized for a highly qualified candidate.


The Lead Medical Records Technician (Medical Coder) is responsible for maintaining the quality of patient records, assigning appropriate International Classification of Diseases Clinical Modification (IDC-10 CM) Current Procedural Terminology (CPT 4) and Healthcare Common Procedure Coding System (HCPCS) codes. The Lead Medical Record Technician (Medical Coder) researches and codes all assigned work based on established or stated priorities.

The duties include but are not limited to:

  • The incumbent codes diagnosis, operations, and procedures based on knowledge of coding systems, including ICD-10 CM, CPT-4, and HCPCS, ensuring that codes are complete and conform to accepted VA regulations, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), ICD coding conventions, and guidelines for optimal reimbursement.

  • Helps staff maintain productivity standards of 70 encounters for outpatient and Pro Fee encounters; 9 PTF without Pro Fees and 6 PTF with Pro Fees.

  • Thoroughly reviews the patient's record to ensure that all conditions of care, operations, and procedures are properly documented by the clinician and sequenced in order of importance.

  • Ensures all documentation is present and in an appropriate format, sequenced, identified and signed ensuring that documentation meets JCAHO, and VA requirements.

  • Reviews patient record before assigning pertinent codes and submitting the most accurate information relating to admissions, operations, procedures, and changes in treating specialty, diagnosis and disposition for each episode of hospitalization at the facility and public and private hospitals paid for by the facility.

  • May attend select committees such as HIMS committee and Compliance Committee.

  • Monitors Coding Related Activities.

  • Completes Patient Treatment File (PTF) for each admission by abstracting pertinent information, including clinical and demographic information.

  • Assists the completion of census, Minimum Data Sets (MDS) for NHCU patients and other special surveys before closeout.

  • Assists in training new personnel and/or students assigned to the department.

  • Ensures that PTF workload is loaded, transmitted and accepted by the 14th of every month, in accordance with Central Office's mandate.

  • Completed inpatient and Pro Fee coding on all inpatient charts within 10 days of discharge.

  • Codes assigned outpatient encounters within 14 days of event.

  • Reviews, audits, trains, monitors, and completes special assignments in specified time frames.

  • Manages time schedules, priorities, deadlines and requests, and maintain productivity standards.

  • Ensures that staff maintains an accuracy rate of 95% based on reviews and/or spot checks.

  • Educates providers through feedback, email queries, or informal meetings.

  • Assists in training new personnel and/or students assigned to the department.

  • Performs other related duties as assigned.

Work Schedule: Monday - Friday - Schedule is negotiable - days, between 6:00 am and 5:00 pm.

Functional Statement: Lead Medical Records Technician (Medical Coder), Business Service Line.

ATTRACTIVE RECRUITMENT INCENTIVE MAY BE AVAILABLE! Please go to the following link for more information on Federal recruitment incentives:

Travel Required
  • Not Required
Relocation Authorized
  • No
Job Requirements
Key Requirements
  • Must be U.S. Citizen.
  • Must pass pre-employment examination.
  • Must be proficient in written and spoken English.
  • Background and-or Security Investigation required.
  • Selective Service Registration is required for males born after 12/31/1959


Citizenship.Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified candidates in accordance with VA policy.)

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 the MRT work.


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).


*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.

(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 U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis 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.

*English Language Proficiency. *MRT's must be proficient in spoken and written English.

Grade Requirements

Knowledge of Current Medical Record Technology. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current health information or health record technology and may be paid or non-paid employment.

Quality of Experience. Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be equivalent to the next lower grade level.

Title. All individuals assigned to this occupation MUST have an approved parenthetical title "Medical Record Technician (Medical Coder)".

Grade Determinations

GS 09 Lead MRT (Medical Coder)

Experience. One year equivalent to the next lower grade level.

In addition to the experience above, the candidate must demonstrate the following Knowledge Skills, and Abilities (KSA's):

  1. Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities of a medical record function 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.;

  2. Comprehensive knowledge of medical record technology theories, methods, procedures, and techniques for assigned areas; and

  3. Ability to communicate tactfully and effectively, both orally and in writing, in order to meet program objectives. This may include preparing reports in various formats and presenting data to various organizational levels.

A*ssignment.* Lead coders review coding and assist coders in improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate various reports and analyze data; and may also coordinate, assign, and monitor the workflow.

For more information on these qualification standards, please visit the United States Office of Personnel Management's website at


Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (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 that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

References:Input applicable VA Handbook 5005/15, Part II, Appendix G-35 of VA Qualification Standard.

PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement.) Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Applicants can verify accreditation at the following website: All education claimed by applicants will be verified by the appointing agency accordingly. 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.

Physical Requirements:The work is sedentary, however, there may be some walking, standing, bending, carrying of light items such as papers, books. No special physical demands are required to perform the work.

*Work Environment: *Work is performed in office suites which are adequately lighted, heated and ventilated.

Veterans' Preference:When applying for Federal Jobs, eligible Veterans should claim preference on the Occupational Questionnaire in the section provided and provide a legible copy of your DD214(s) and/or documentation related to your active duty service which shows dates of service, character of service (honorable, general, etc.), or dates of impending separation.

Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veterans Preference" with required proof as stated on the form. For more information, please review the information for disabled Veterans in the application checklist or visit

Security Clearance


Additional Information
What To Expect Next

After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. During our review, if your résumé and application package do not support your questionnaire answers, we will adjust your rating accordingly. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email (if provided); otherwise, applicants will receive a notification letter via the U.S. Postal Service. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USAJOBS account and clicking on “Application Status.” For a more detailed update of your status, click on “more information.” Information regarding applicant notification points can be found in the USAJobs Resource Center.


VA offers a comprehensive benefits package. This link provides is an overview of the benefits currently offered:

Other Information

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

Salary Range: $48,968.00 to $63,654.00 / Per Year

Series & Grade: GS-0675-09/09

Promotion Potential: 09

Supervisory Status: No

Who May Apply: United States Citizens

Control Number: 452072300

Job Announcement Number: VHA-402-16-LLR-1814350