Medical Records Technician (Coder Outpatient and Inpatient)

Medical Records Technician (Coder Outpatient and Inpatient)

Department: Department of Veterans Affairs

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

Salary Range: $37193 - $72516 Per Year

Job Summary: MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Major Duties:

• Announcement will close once 50 applicants is reached-Temporarily eligible for Remote work within 50 miles of a VA Medical Center. May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review. Total Rewards of a Allied Health Professional Selects and assigns codes from current ICD, CPT, and/or HCPCS coding systems for inpatient and outpatient encounters across the full range of VAMC health care services. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, procedures, and health services practices to ensure accurate code selection. Adheres to accepted coding practices and guidelines to ensure ethical, accurate, and complete code selection across diagnoses, procedures, and E/M services. Applies VERA program coding criteria to classify VA patients into appropriate classes based on clinical conditions and resource needs. Assists facility staff with documentation requirements to accurately reflect patient care. Provides technical support on regulations, coding requirements, reimbursement, and proper sequencing. Consults directly with clinical staff to clarify conflicting or ambiguous data and reports documentation or coding errors in the electronic health record. Uses facility systems and software to code, abstract, record, and transmit data to national VA databases. Corrects errors or inconsistencies within established timelines and independently researches references to resolve questionable coding issues, escalating to a supervisor as needed. May be assigned one or more of the following regular or recurring duties: Identifies the principal diagnosis, principal procedure, and significant complications or co-morbidities for every inpatient discharge to determine the proper DRG. Codes admission diagnoses for Community Living Center/Nursing Home Care Unit admissions using the current ICD coding system. Re-reviews inpatient and outpatient codes identified by the VERA committee to verify compliance with VERA coding requirements, correcting codes as needed to ensure proper patient classification. Establishes diagnosis and procedure codes for outpatient fee encounters per reimbursement regulations, linking diagnoses to procedures and determining E/M service levels. Applies CPT coding nuances for Third Party Insurance recovery, bundles encounters appropriately, and communicates billing issues to CPAC staff. Codes all surgical procedures using ICD and CPT guidelines and the encoder product suite, adding Anesthesia and Pathology codes for all billable cases, including creating encounters as needed. Update codes for inpatient and Contract Nursing Home admissions for quarterly census and billable long-stay (30+ days) admissions to reflect all conditions and care through the census or billing date. May be required to review and enter coded data from paid Community Care claims using documentation (e.g., hard-copy claims) obtained from non-VA facilities. Work Schedule: Monday-Friday 7:30 am - 4:00 pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available-this is a remote position Virtual: This is a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized

Qualifications: Basic Requirements: U.S. Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Experience & Education: Must meet ONE of the following 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; 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); Education 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. Dept. of Education accreditor, or comparable international accrediting authority at the time the program was completed; 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. Certification: 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: IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. GS-4 Experience or Education. None beyond basic requirements. GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; 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 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, Centers for Medicare and Medicaid Services (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. 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.vi. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG. SEE EDUCATION SECTION BELOW FOR GS-7 AND GS-8 Grade Requirements Preferred Experience: Hold a AAPC/AHIMA specialty coding certification in one or more following areas and/or have creditable work experience as a seasoned coder: - Experience with standardized mortality ratios (SMR), including acute care and ICU 30 day and in hospital mortality measures - Inpatient (Acute Care, Domiciliary, CLC, SNF) Coding - Inpatient Appointments/Professional Fees Coding - Surgery Coding - Outpatient Coding - Prosthetics/DME Coding Experience with VA, EPIC or Cerner EHRM Experience with 3M Coding and Reimbursement Systems Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.Medical Records Technician Qualification Standard 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-4 to GS-8. Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of evaluation or examination.

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 04/30/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12940519. 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: 2026-04-30