Veterans Health Administration Logo
Position Title
Medical Records Technician (Coder-Outpatient and Inpatient)
Agency
Veterans Health Administration
Announcement Number
CBTC-12724479-25-JW Opens in new window
Open Period
Wednesday, April 16, 2025 to Wednesday, May 21, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1. Are you currently employed by the Department of Veterans Affairs?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.

To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50).  Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted).  Please be aware that award SF-50's do not always include this pertinent information.
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2. Are you an employee of the facility indicated for this position?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.

To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50).  Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted).  Please be aware that award SF-50's do not always include this pertinent information.
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3. Are you a current permanent Federal employee from an agency other than Department of Veterans Affairs?

To verify your eligibility, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50) or equivalent personnel action form.
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Preferences
1. Select the lowest grade you are willing to accept for this position. (limit characters)
2. Which of the following items describes your current or recent (within the last five years) political appointee service?

If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
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Your resume must be submitted in English and include the following information for each job listed:
  • Job title Duties (be as detailed as possible)
  • Month & year start/end dates (e.g. June 2007 to April 2008)
  • Full-time or part-time status (include hours worked per week)
  • Series and Grade, if applicable, for all Federal positions you have held
  • Please be aware that your answers will be verified against information provided on your resume. Be sure that your resume clearly supports your responses to all of the questions by addressing your work experience in detail.
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications. Do not include a photograph or video of yourself, or any sensitive information (age, date of birth, marital status, protected health information, religious affiliation, social security number, etc.) on your resume or cover letter. We will not access web pages or encrypted, and digitally signed documents linked on your resume or cover letter to determine your qualifications.
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By submitting your application, you are certifying, to the best of your knowledge and belief, all the information submitted by you with your application for employment is true, complete, and made in good faith, and that you have truthfully and accurately represented your work experience, knowledge, skills, abilities and education (degrees, accomplishments, etc.). The information you provide as part of your application may be investigated. You are also certifying, and acknowledging, that misrepresenting your experience or education, or providing false or fraudulent information in, or with your application, may affect your eligibility for appointment and/or continued employment. False or fraudulent statements may be punishable by fine or imprisonment (18 U.S.C. 1001). (limit characters)
3. I authorize my application information being shared with hiring managers for similar positions. I understand this option may not result in further consideration for additional positions nor will it impact my application for this announcement. (limit characters)
Assessment 1
Thank you for your interest in a Medical Record Technician (Coder-Outpatient and Inpatient) position. We will evaluate your resume and your responses to this Assessment Questionnaire to determine if you qualify for this position. Your responses are subject to verification. Please review your responses for accuracy before you submit this questionnaire. Choose the one answer that best describes how you meet the qualification requirements for the Medical Record Technician (Coder-Outpatient and Inpatient) position as described in the Qualifications Section of the Vacancy Announcement.

***This announcement is not for insurance coders.***

Full performance level for this position is GS-8. Grade levels that you may be selected for are GS-4, 5, 6, 7 or 8.
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BASIC REQUIREMENTS: The following section is used to determine if you meet the basic requirements for this vacancy. Please choose the most appropriate answer in response to the following questions. (limit characters)
Select “Yes” or “No” to the following question(s). (limit characters)
1. 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.)

Are you a United States Citizen?
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2. English Language Proficiency:

MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).

Are you proficient in spoken and written English language?
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3. Certification requirements:

Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(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.

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.

Current Apprentice/Associate level certifications include: Certified Coding Associate (CCA), Certified Professional Coder-Apprentice (CPC-A) and Certified Outpatient Coding- Apprentice (COC-A).

Do you possess Apprentice/Associate Level Certification through AHIMA or AAPC?
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4. Basic Experience and Education (GS-4 level):

Please identify which of the following you possess to meet the minimum entry level requirement. Select the statement below that best describes your ability to meet the basic requirements for this position.

THIS MUST BE CLEARLY REPRESENTED IN YOUR RESUME TO BE FOUND QUALIFIED. WE WILL NOT MAKE ASSUMPTIONS ABOUT YOUR EXPERIENCE.
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GRADE DETERMINATIONS (limit characters)
Select “Yes” or “No” to the following question(s). (limit characters)
5. Medical Records Technician (Coder-Outpatient and Inpatient), GS-5

Experience. One year of creditable experience equivalent to the next lower grade level; OR,

Education. Successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education, 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.

Assignment. Employees at this grade level serve as developmental level 1 MRTs (Coder) and receive guidance from more experienced MRTs (Coder) for more complex coding procedures. Selects and assigns codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, 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 (e.g., the electronic health record, coding and abstracting software, etc.).
  2. Ability to navigate through and abstract pertinent information from health records.
  3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
  4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care 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 coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues
Do you possess the requirements for the GS-5 grade level?
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6. Medical Records Technician (Coder-Outpatient and Inpatient), GS-6

Experience. One year of creditable experience equivalent to the next lower grade level.

Assignment. Employees at this grade level serve in developmental level 2 positions as MRTs (Coder) and receive intermittent monitoring. MRTs (Coder) perform a combination of inpatient and outpatient coding duties. They select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They 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). They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and 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 Health Insurance Portability and Accountability Act (HIPAA)).
  4. Ability to accurately apply the ICD CM, Procedure Coding System (PCS) Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines to coding scenarios.
  5. Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
  6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.
Do you possess the requirements for the GS-6 grade level?
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7. Medical Records Technician (Coder-Outpatient and Inpatient), GS-7

Experience. One year of creditable experience equivalent to the next lower grade level.

Assignment. Employees at this grade level serve as developmental level 3 MRTs (Coder) and receive minimal monitoring. MRTs (Coder) perform a combination of inpatient and outpatient coding duties. Selects and assigns codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with minimal guidance from higher level MRTs (Coder). They review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. They also query clinical staff with documentation requirements to support the coding process. They use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  1. Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
  2. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
  3. Ability to research and solve coding and documentation related issues.
  4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
  5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG
Do you possess the requirements for the GS-7 grade level?
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8. Medical Records Technician (Coder-Outpatient and Inpatient), GS-8

Experience. One year of creditable experience equivalent to the next lower grade level.

Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. They code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. They directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. They abstract, assign, and sequence codes into encoder software to obtain correct diagnosis-related DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. They review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. They query clinical staff with documentation requirements to support the coding process. They enter and correct information that has been rejected, when necessary. They correct any identified data errors or inconsistencies. They also ensure audit findings have been corrected and refiled. They use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, 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. 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.
  2. 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.
  3. 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
Do you possess all of the requirements for the GS-8 grade level?
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FINAL INSTRUCTIONS:  

PLEASE DO NOT INCLUDE A PHOTO IN YOUR RESUME

RESUME REMINDER: Your resume must include the following information for each job listed:
  • Job title Duties: be as detailed as possible
  • Month & year start/end dates (e.g. June 2017 to April 2021)
  • Full-time or part-time status (include hours worked per week). Part-time experience is creditable according to its relationship to the full-time work week. For example, one week of full-time credit is equivalent to two weeks of half-time work. 
  • Series and Grade for all Federal positions you have held.
Please be aware that your answers will be verified against information provided on your resume. Be sure that your resume clearly supports your responses to all of the questions by addressing your work experience in detail. 

Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. ***We cannot make assumptions regarding your qualifications.*** 

SF-50 Reminder for Federal Employees: Must be most current to verify eligibility and show position, grade, and status. "Award" SF-50s are NOT acceptable. **Note* SF-50 must be an updated one (2025)** You may be required to provide more than one SF-50. If your most recent SF-50 has an effective date (shown in box 4) within the past year, it may not clearly demonstrate you possess the 1 full year of specialized experience in your present grade, as required by the announcement. In this instance, you must provide an additional SF-50, prior to your most recent one. The yearly Cost of Living Adjustment SF-50, issued in January, does not prove a full year of specialized experience. Monetary or time off award SF-50's do not provide sufficient information and will not be accepted. 

Transcripts Reminder: If you are basing your qualifications on education (or a combination of education and experience) you must submit a copy of your transcripts (official or unofficial) with your application. Be sure your name, name of the school attended, dates attended, and any degree conferred, or certificate issued is stated on the transcript. This information is used to verify qualifications and accreditation. 

Professional Certification Reminder: You must submit a copy of a current active certification. Expired certifications will not be considered. Please make sure you submit all required documentation before the closing date of the announcement. You will not be able to submit documents after the closing date of this announcement. 

FAILURE TO SUBMIT THE APPROPRIATE SUPPORTING DOCUMENTS WILL CAUSE YOU TO BE INELIGIBLE FOR CONISDERATION OF THIS POSITION.
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