Medical Records Technician

Total Rewards of a Allied Health Professional

Functions of this position include but are not limited to the following:

• Applies comprehensive knowledge of medical terminology anatomy & physiology disease processes treatment modalities diagnostic tests medications procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Reviews assigned codes from the current version of several coding systems to include current versions of ICD CPT and/or HCPCS.
• Adheres to accepted coding practices guidelines and conventions when validating 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.
• 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.
• Audits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes MS-DRG POA status and discharge disposition values for inpatient health records.
• Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyzes data.
• Performs audits of coded data developing criteria collecting data graphing trending and analyzing results creating reports and communicating in writing and/or in person to appropriate leadership and groups.
• Analyzes audit results and prepares summary feedback for individual coders and/or clinicians making recommendations for improvement.
• Provides coding consultation to coders and/or clinicians related to coding and documentation questions.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices

• 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:

• 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 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
  • Experience/Education Combination. 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 4 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).
• Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) (2) or (3) below. NOTE: Mastery level certification is required for all positions above the journey level; however for clinical documentation improvement specialist assignments a clinical documentation improvement certification may be substituted for a mastery level certification:
  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.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f)

• Auditor assignments can be established for any of the coder subspecialties (outpatient inpatient or outpatient and inpatient combined). The subspecialty will be reflected in the title e.g. MRT (Coder) Auditor (Outpatient).
• Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder).
• Certification. Employees at this level must have a mastery level certification. NOTE: See paragraph 2g for a detailed definition of mastery level certification.
• Demonstrated Knowledge Skills and addition to the experience above the candidate must demonstrate all of the following KSAs:
  • Advanced knowledge of current coding classification systems such as ICD CPT and HCPCS for the subspecialty being assigned (outpatient inpatient outpatient and inpatient combined).
  • Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  • Ability to review coded data and supporting documentation to identify adherence to applicable standards coding conventions and guidelines and documentation requirements.
  • Ability to format and present audit results identify trends and provide guidance to improve accuracy.
  • Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.