Medical Records Technician (Coder-Outpatient)

Medical Records Technician (Coder-Outpatient)

Department: Department of Veterans Affairs

Location(s): Oklahoma City, Oklahoma

Salary Range: $36825 - $71932 Per Year

Job Summary: This Health Information Management (HIM) position at the Oklahoma City VA Health Care System involves classifying medical data from patient records in various settings, including hospitals and outpatient facilities. MRTs (Coder) analyze health records and assign alpha-numeric codes for diagnoses and procedures using ICD, CPT, and HCPCS. They may also provide education on coding and documentation.

Major Duties:

• Total Rewards of a Allied Health Professional Applies knowledge of medical record content, terminology, anatomy, physiology, disease processes, and official coding guidelines to assign basic and routine outpatient or inpatient professional service codes. Selects and assigns codes from current versions of ICD, CPT, and/or HCPCS. Learns to select diagnosis, operation, or procedure codes based on accepted coding practices, guidelines, conventions, and policies with instruction from a senior coder or supervisor. Reviews record documentation to abstract required medical, surgical, ancillary, demographic, social, and administrative data, developing an understanding of the organization and structure of an electronic patient record under guidance. Refers coding and documentation questions from providers to a senior coder or supervisor for resolution or guidance. Utilizes the facility's computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin; reviews identified data errors with a senior coder or supervisor and makes corrections as directed. Uses a variety of computer applications, including Outlook, Excel, Word, and Access, and develops proficiency with health record applications (VistA and CPRS) and the encoder product suite. Performs other duties as assigned depending on grade level. Work Schedule: Full-time, Monday-Friday, 8:00am-4:30pm Pay: Competitive salary and regular salary increases 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: This position is eligible for 100% Telework, with the understanding that selected candidates must reside within 50 miles of a VISN 19 facility. Although this position currently allows for 100% telework and are exempt from the return-to-office (RTO) policy, the position(s) may fall under the Presidential Memorandum titled "Return to In-Person Work" which will require you to go into the office if the exception is not approved when it is up for review. Functional Statement #: 635-58044-A, 635-58045-A, 635-58046-A, 635-58047-A, 635-58048-A

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: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 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. 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. Grandfathering Provision. 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 Level Requirements: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Medical Records Technician (Coder-Outpatient), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (Coder-Outpatient), GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; -OR- Education. Successful completion of four years of education above high school leading to a bachelor's degree from an accredited college or university. 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 outpatient/ambulatory surgery records, based on health record documentation. v. 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, in order to complete duties within required timeframes, and the ability to follow-up on pending issues. Medical Records Technician (Coder-Outpatient), 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 outpatient coding and 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 Health Insurance Portability and Accountability Act (HIPAA)). Ability to accurately apply the ICD CM, procedure coding system (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios. v. Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation. Medical Records Technician (Coder-Outpatient), 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 specialty care areas for outpatient episodes of care and/or inpatient professional services 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, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder 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. Medical Records Technician (Coder-Outpatient), 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 findings, 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/or inpatient professional fee services coding. 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. 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-4. 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: In accordance with VA Handbook 5019 - Employee Occupational Health Service.

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 11/10/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12828422. 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: 2025-11-10