Medical Records Technician (Coder Inpatient)

• 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.

As a condition of employment for accepting this position you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public determining if your employment advances the public interest we may consider:

• 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.

Upon completion of your trial period your employment will be terminated unless you receive certification in writing that your continued employment advances the public interest.

BASIC REQUIREMENTS.

(a) United States Citizenship: Must be a U. S. citizen.
(b) English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English.
(c) Certification. MRT (Coder) GS-0675 must have either (1) (2) or (3) below:

(1) Apprentice/Associate Level Certification through AHIMA or AAPC.

• Certified Coding Associate (CCA)
• Certified Professional Coder-Apprentice (CPC-A)
• Certified Outpatient Coding-Apprentice (COC-A)

(2) Mastery Level Certification through AHIMA or AAPC.

• Certified Coding Specialist - Physician-based (CCS-P)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Certified Professional Coder (CPC)
• Certified Outpatient Coder COC)
• Certified Inpatient Coder (CIC)
• Certified Coding Specialist (CCS)

(3) Clinical Documentation Improvement

• Certification through AHIMA or ACDIS.
• Clinical Documentation Improvement Practitioner (CDIP)
• Certified Clinical Documentation Specialist

(1) Experience. One year of creditable experience that indicates knowledge of medical terminology anatomy physiology pathophysiology medical coding & the structure/format of a health record.
OR
(2) Education. An associates degree from an accredited college/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 & physiology medical coding & introduction to health records).
OR
(3) Completion of an AHIMA approved coding program /other intense coding training program of approximately one year or more that included courses in anatomy and physiology medical terminology basic ICD diagnostic/procedural & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination the sponsoring academic institution must be accredited by a national U.S. Department of Education accreditor/comparable international accrediting authority at the time the program was completed

(4) Experience/Education Combination. Equivalent combinations of creditable experience/education are qualifying for meeting the basic requirements.
(a) Six months of creditable experience that indicates knowledge of medical terminology general understanding of medical coding & the health record and one year above high school with a minimum of 6 semester hours..
(b) Successful completion of a course for medical technicians hospital corpsmen medical service specialists/hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical professional supervision.

GRADE DETERMINATIONS AND ASSIGNMENTS.

(1) Medical records Technician (Coder-Inpatients) GS-4
(a) Experience or Education- None beyond basic requirements above.

(2) Medical records Technician (Coder-Inpatients) GS-5
(a) Experience. One year creditable experience equivalent to the next lower grade level
OR
(b) Education. Successful completion of a bachelors degree from accredited college or university.
(c) (Demonstrated Knowledge Skills and Abilities (KSAs). In addition to the experience the candidate must demonstrate all of the following KSAs:
1. Ability to use health information technology and various office software products used in MRT (Coder) positions.
2. Ability navigate through and abstract pertinent information from health records.
3. Knowledge of the ICD CM and PCS Official Conventions and Guidelines for Coding and reporting.
4. Ability to apply knowledge of medical terminology human anatomy/physiology and disease processes to accurately assign codes to inpatient records based on health record documentation.
5. Knowledge of The Joint Commission requirements CMS and/or health record documentation guidelines.
6. Ability to manage priorities and work to complete duties within the required timeframes and the ability to follow-up on pending issues.

(3) Medical records Technician (Coder-Inpatients) GS-6
(a) Experience. One year creditable experience equivalent to the next lower grade level
(Demonstrated Knowledge Skills and Abilities (KSAs). In addition to the experience the candidate must demonstrate all of the following KSAs:
1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
2. 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.
3. Ability to apply laws and regulations on the confidentiality of health information (e.g. Privacy Act Freedom of Information Act and HIPAA).
4. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios.
5. Comprehensive knowledge of current classification systems such as ICD Clinical Modification (CM) and PCS CPT and HCPCS and skill in applying said classifications to inpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity(CC/MCC) and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG).

(4) Medical records Technician (Coder-Inpatients) GS-7
(a) Experience. One year creditable experience equivalent to the next lower grade level
(Demonstrated Knowledge Skills and Abilities (KSAs). In addition to the experience the candidate must demonstrate all of the following KSAs:
in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
to communicate with clinical staff for specific coding and documentation issues such as recording diagnoses and procedures the correct sequencing of diagnoses and/or procedures and the relationship between health record documentation and code assignment.
to research and solve coding and documentation related issues.
in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
to abstract assign and sequence codes including complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.

(5) Medical records Technician (Coder-Inpatients) GS-8
(a) Experience. One year creditable experience equivalent to the next lower grade level
(Demonstrated Knowledge Skills and Abilities (KSAs). In addition to the experience the candidate must demonstrate all of the following KSAs:
to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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.
to accurately perform the full scope of inpatient coding including inpatient discharges surgical cases diagnostic studies and procedures and inpatient professional services.
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..

Physical Requirements: The work is primarily sedentary. There is walking bending & reaching required such as for filing or locating material & carrying items such as reports documents/supplies.