Medical Records Technician (Coder InpatientOutpatient)

***THIS IS AN ON SITE POSITION YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION***

Duties of the Medical Records Technician (Coder) In/Outpatient include but not limited to:

• Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC.
• Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Performs a comprehensive review of the patient health record to abstract medical surgical ancillary demographic social and administrative data to ensure complete data capture. Patient health records may be paper or electronic.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy coding requirements resident supervision reimbursement workload accepted nomenclature and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.
• Utilizes the facility computer system and software applications to correctly code abstract record and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• 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.
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs at the direction of the supervisor on unit operations coding abstracting and use of an electronic health record.
• Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Conducts re-reviews of codes abstracted for outpatient/inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
• Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
• Establishes the primary and secondary diagnosis and procedure codes for outpatient/inpatient encounters 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. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
• Reviews and codes assigned fee service Care in the Community outpatient/inpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals Emergency Rooms military facilities etc.
• Codes diagnoses from paper forms for VA registries such as Agent Orange Ionizing Radiation Persian Gulf Prisoner of War etc.

Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7 2025 drivers licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the Required Documents section of this announcement.

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

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.

This is an OPEN CONTINUOUS ANNOUNCEMENT and will remain open until June 22 2026. The initial cut-off date for referral of eligible applications will be February 22 2026 with subsequent cut-off dates on the 22nd of each month. Eligible applications received after that date will be referred at regular intervals or as additional vacancies occur on an as-needed basis until positions are filled.

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. MSAs must be proficient in spoken and written English in accordance with VA Handbook 5005 Part II Chapter 3 Section A paragraph 3.

AND:

Experience and Education-Documentation Submitted

• 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.

• An associates 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);

• 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;

• 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). Please select the proper response for your experience and/or education.

• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

• 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.