Medical Record Technician (Coder-Outpatient and Inpatient)

Total Rewards of a Allied Health Professional

• Assign diagnosis and procedure codes to the most basic and routine inpatient admissions and outpatient encounters. Develop skill and knowledge of medical record coding. Has basic knowledge of medical terminology anatomy & physiology and pathophysiology.
• Learn to select diagnosis and/or procedure codes based on the accepted coding practices guidelines conventions and policies with guidance from a senior coder or supervisor.
• Identifies the principal diagnosis and/or principal procedure for every inpatient admission.
• Adheres to accepted coding practices guidelines and conventions when choosing the most appropriate code to ensure ethical accurate and complete coding.
• Reviews medical record documentation to abstract all relevant clinical demographic social and administrative data with guidance and instruction from supervisor or senior coder.
• Assist in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs with the direction of the supervisor.
• Work within a team environment supporting peers handle multiple tasks meet goals and work with frequently changing projects and deadlines.
• Utilize advanced knowledge of encoder software and use a variety of Windows based applications in day to day activities and duties such as Outlook Excel and Word. Performs other related duties as assigned.

• 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 identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• 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.

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:

Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3 section A paragraph 3g this part.)

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 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); 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

• 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).

1. Apprentice/Associate Level Certification through AHIMA or AAPC.
2. Mastery Level Certification through AHIMA or AAPC.
3. 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.