Medical Records Technician (Coder In/Out)

Medical Records Technician (Coder In/Out)

Department: Department of Veterans Affairs

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

Salary Range: $36409 - $72644 Per Year

Job Summary: This Medical Records Technician Coder (In/Out) position is in support of the Health Information Management Section (HIMS) of the White River Junction VA Medical Center.

Major Duties:

• Medical Record Technicians (MRT) Coders are responsible for classifying medical data from patient health records in the hospital or physician-based settings such as physician offices, group practices, multispecialty clinics, and specialty centers. MRTs analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. Major duties include but are not limited to: Assigns codes to inpatient admissions; develops skill and knowledge of health record coding. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, to ensure ethical, accurate, and complete coding. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Codes inpatient admission to obtain the most appropriate MS-DRG, including all MCCs, CCs, correct POAs to support VERA and 3rd party reimbursement. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), and the Procedural Coding System (PCS). Selects diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. Reviews health record documentation to abstract all required medical, surgical, demographic, social, and administrative data. Patient health records maybe paper or electronic. Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database. Operates a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access. Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance. Work Schedule: Full time, Days Virtual/Remote Work Status: This position is eligible for Remote/Virtual work. However, this position may fall under the Presidential Memorandum titled "Return to In-Person Work" which requires you to go into the office. By applying to this position, you are acknowledging that you maybe be required to report in person to a designated location deemed by management. Functional Statement #: 402-F03429, F03469, F03468, F03467, F03478 Notifications: Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held.

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. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Basic Requirements: United States Citizenship English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f). Experience and Education Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. 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, medical coding, and introduction to health records); OR, Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. 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 health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).AND Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either one of below: Apprentice/Associate Level Certification through AHIMA or AAPC Mastery Level Certification through AHIMA or AAPC Clinical Documentation Improvement Certification through AHIMA or ACDIS NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. 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 (MRT), (Coder-In/Out), GS-04 (a) Experience or Education. None beyond basic requirements. MRT (Coder-In/Out), GS-05 (a) Experience, One year of creditable experience equivalent to the next lower grade level; OR (b) 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. (c) 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.). Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. MRT (Coder-In/Out), GS-06 : (a) Experience, One year of creditable experience equivalent to the next lower grade level. (b) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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 Medicare Severity Diagnosis Related Group (MS-DRG) MRT (Coder-In/Out), GS-07: (a) Experience, One year of creditable experience equivalent to the next lower grade level. (b) 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. 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-DR. MRT (Coder-In/Out), GS-08: (a) Experience, One year of creditable experience equivalent to the next lower grade level. (b) 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 inpatient discharges, surgical cases, diagnostic studies and procedures. 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. The full performance level of this vacancy is GS-08. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-08. References: VA Handbook 5005/12, Part II, Appendix G57 Physical Requirements: Position is mostly sedentary, in an office type setting. Some light lifting ( under 15 lbs.), Light carrying ( under 15 lbs.), use of fingers to keyboard, and ability to read electronic health records on computer screen.

How to Apply: All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 05/13/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12948270. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

Application Deadline: 2026-05-13