Medical Records Technician (Coder-Outpatient)

Medical Records Technician (Coder-Outpatient)

Department: Department of Veterans Affairs

Location(s): Oklahoma City, Oklahoma

Salary Range: $36409 - $72644 Per Year

Job Summary: The Oklahoma City VA Medical Center, Health Information Management (HIM) Service, is currently recruiting for one (1) Medical Records Technician (Coder-Outpatient) in Oklahoma City, OK. This position is located in the Health Information Management (HIM) section at the Oklahoma City VA Health Care System.

Major Duties:

• *Complete all application requirements detailed in the "Required Documents" section of this announcement.* Total Rewards of a Allied Health Professional Major Duties and Responsibilities: 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. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Select and assign codes from current versions of ICD-10-CM, CPT, and HCPCS classification systems. Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with limited guidance from higher level MRTs (Coder). Utilize various computer applications to abstract records, assign codes, and record and transmit data. Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) for one or more specialty and subspecialty health care services provided by the VAMC. Has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD) Clinical Modification (CM), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). 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. Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing. Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts supervisor when needed. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks. Work Schedule: Monday - Friday; 7:30 a.m. - 4:00 p.m. Compressed/Flexible: Not Authorized. Recruitment Incentive (Sign-on Bonus): Not Authorized. Permanent Change of Station (Relocation Assistance): Not Authorized. 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) 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 currently has a Return to Office (RTO) mid-term extension (180-days). Remote work is currently authorized; however, candidates may be subject to return to office in the event policy changes or the exemption is not extended. Virtual: This is not a virtual position. Functional Statement #: 58044-A; 58045-A; 58046-A; 58047-A; 58048-A Permanent Change of Station (PCS): Not Authorized

Qualifications: 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. 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.- 1 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 - Associate's degree from an accredited college or university recognized by the U.S. DOE 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 1 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. The sponsoring academic institution must have been accredited by a national U.S. DOE 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. 6 months of creditable experience that indicates knowledge of medical 4 terminology, general understanding of medical coding and the health record, and 1 year above high school, with a minimum of 6 semester hours of health information technology courses. 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 6 months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires 6 additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder) Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have one of the 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 (Current VHA employees only) Grade Determinations In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates: GS-4 MRT(Coder-Outpatient) Experience or Education. None beyond basic requirements. GS-5 MRT(Coder-Outpatient) Experience. 1 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 recognized by the U.S. DOE, 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. GS-5 Demonstrated KSA's. 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. 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. 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. GS-6 MRT(Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level. GS-6 Demonstrated KSA's. 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. Ability to accurately apply the ICD CM, PCS and CPT guidelines to coding scenarios. 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. GS-7 MRT (Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level. GS-7 Demonstrated KSA's 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 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. GS-8 MRT(Coder-Outpatient) Experience. 1 year of creditable experience equivalent to the next lower grade level. GS- 8 Demonstrated KSA's. 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, 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 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. The ability to use judgment in completing assignments using incomplete or inadequate guidelines. The full performance level is GS 8. The actual grade that an applicant may be selected is in the range of 4 to 8 .

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 05/11/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12950493. 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: 2026-05-11