Med Rec Tech (Med Coder Inpatient and Outpatient)

Med Rec Tech (Med Coder Inpatient and Outpatient)

Department: Department of Veterans Affairs

Location(s): Anywhere in the U.S. (remote job), United States

Salary Range: $36409 - $85609 Per Year

Job Summary: Medical Records Technician (Coder - Outpatient and Inpatient) analyzes and abstracts patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, he/she must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

Major Duties:

• This position is in the Health Information Management Service (HIMS) at the VA Western New York Health Care System (VAWNYHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings. GS-4 Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding. Incumbent with instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. GS-5 Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement. Links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. Uses basic knowledge of the CPT and HCPCS coding systems for Third Party Insurance cost recovery Codes less complex Operating Room procedures reported in the Surgical Package of the VistA hospital system Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions; Applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite Incumbent updates any assigned billable long stay (30+ days) inpatient admissions to reflect all patient conditions and care up for monthly billing. GS-6 Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC Incumbent has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Incumbent selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Incumbent monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment. Incumbent at the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs. GS-7 Receives minimal monitoring. MRTs (Coder) perform a combination of inpatient and outpatient coding duties Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Incumbent adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. GS-8 Incumbent is at the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Independently plans and executes tasks related to medical record coding and documentation. Incumbent expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Work Schedule: Monday - Friday 7:00am - 3:30pm Functional Statement #: PD11347F Financial Disclosure Report: Not required

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: See education requirements Grade Determinations: Medical Records Technician, GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Outpatient and Inpatient), GS-5 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. 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, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care 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-Outpatient and Inpatient), GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. 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, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios. Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. Medical Records Technician (Coder-Outpatient and Inpatient), GS-7 Experience. One year of creditable experience equivalent to the next lower grade level. 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 and outpatient 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 inpatient and outpatient 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-Outpatient and Inpatient), GS-8 Experience. One year of creditable experience equivalent to the next lower grade level. 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. 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 outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility 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 inadequate guidelines. NOTE: Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS 04-GS-08. Preferred Experience: Five (5) years of Medical Coding experience. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

How to Apply: Please read the entire announcement and all the instructions before you begin an application. To apply for this position, you must complete the initial online application, to include the initial online questionnaire and submission of the required documentation specified in the How to Apply and Required Documents section. The complete application package must be submitted by 11:59 PM (ET) on the closing date of the announcement to receive consideration. To preview the application questionnaire, click https://apply.usastaffing.gov/ViewQuestionnaire/12938353. The application process is as follows: To begin, click Apply Online to create a USA JOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents. Answer the questions presented in the application and attach all necessary supporting documentation. Click the Submit Application button prior to 11:59 PM (ET) on the announcement closing date, 04/23/2026. If you are required to complete any USA Hire Assessments, you will be notified after submitting your application. The notification will be provided in your application submission screen and via email. The notification will include your unique assessment access link to the USA Hire system and the completion deadline. Additionally, in USAJOBS you can click "Track this application" to return to your assessment completion notice. Access USA Hire using your unique assessment link. Access is granted through your USAJOBS login credentials. Review all instructions prior to beginning your assessments. You will have the opportunity to request a testing accommodation before beginning the assessments should you have a disability covered under the Rehabilitation Act of 1973 as amended. Set aside at least 3 hours to take the USA Hire Assessments; however, most applicants complete the assessments in less time. If you need to stop the assessments and continue later, you can re-use your unique assessment link. NOTE: Your responses to the USA Hire Assessments will be reused for one year (in most cases) from the date you complete an assessment. If future applications you submit require completion of the same assessments, your responses will be automatically reused. Visit the USA Hire Applicant Resource Center for practice assessments and assessment preparation resources at https://support-usahire.opm.gov/hc/en-us. To update your application, including supporting documentation: During the announcement open period, return to your USAJOBS account, find your application record, and click Edit my application. This option will no longer be available once the announcement has closed. To view the announcement status or your application status: https://help.usajobs.gov/how-to. Your application status page is where you can view your application status, USA Hire assessment completion status, and review your notifications sent by the hiring agency regarding your application. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

Application Deadline: 2026-04-23