- Position Title
- Medical Records Technician (Coder-Outpatient and Inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBSV-12727872-25-DMJ Opens in new window
- Open Period
- Monday, April 21, 2025 to Thursday, May 1, 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.
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.
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.
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.
3.
Are you a current/past/upcoming VHA Health Professions Trainee (HPT) Graduate?
An HPT may be VA-paid, Without Compensation (WOC), or a participant of the VA Health Professional Scholarship Program that has been appointed to a temporary position in one or more VHA medical facilities performing clinical or research training experience to satisfy program or degree requirements.
To verify your standing as a current/past/upcoming HPT graduate, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50), the FL-294 (or a WOC appointment letter).
An HPT may be VA-paid, Without Compensation (WOC), or a participant of the VA Health Professional Scholarship Program that has been appointed to a temporary position in one or more VHA medical facilities performing clinical or research training experience to satisfy program or degree requirements.
To verify your standing as a current/past/upcoming HPT graduate, you must submit a copy of your latest Notification of Personnel Action, Standard Form 50 (SF-50), the FL-294 (or a WOC appointment letter).
Preferences
1.
Select the lowest grade you are willing to accept for this position.
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.
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
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.
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).
Assessment 1
Thank you for your interest in a career with the VA. The following questions will determine if you meet the minimum qualifications for the Medical Records Technician (Coder-Outpatient) position.
Select the appropriate answer to each of the following questions based on your current level of experience that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that your experience is subject to verification by investigation. You may be asked to provide specific examples or documentation of experience as proof to support your answers, or you may be required to verify a response by a practical demonstration of your claimed ability to perform a task. If your resume does not support your questionnaire answers, we will not allow credit for your response(s).
Select the appropriate answer to each of the following questions based on your current level of experience that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that your experience is subject to verification by investigation. You may be asked to provide specific examples or documentation of experience as proof to support your answers, or you may be required to verify a response by a practical demonstration of your claimed ability to perform a task. If your resume does not support your questionnaire answers, we will not allow credit for your response(s).
BASIC REQUIREMENTS
The following section is used to determine your eligibility for this vacancy. Your application must provide acceptable proof of your status. Please choose an answer for each of the following items to identify which of the following descriptions applies to you.
The following section is used to determine your eligibility for this vacancy. Your application must provide acceptable proof of your status. Please choose an answer for each of the following items to identify which of the following descriptions applies to you.
Select “Yes” or “No” to the following question(s).
1.
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 both written and spoken English?
MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
Are you proficient in both written and spoken English?
2.
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 associate'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 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:
NOTE: If utilizing education or experience/education combination, must provide transcripts with conferred date
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 associate'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 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 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).
NOTE: If utilizing education or experience/education combination, must provide transcripts with conferred date
3.
Certification:
Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
- Apprentice/Associate Level Certification through AHIMA or AAPC.
- Mastery Level Certification through AHIMA or AAPC.
- Clinical Documentation Improvement Certification through AHIMA or ACDIS.
GRADE REQUIREMENTS
The following section is used to determine your eligibility for this vacancy. Your application must provide acceptable proof of your experience. Please choose A (Yes) or B (No) for each of the following items to identify which of the following descriptions applies to you.
The following section is used to determine your eligibility for this vacancy. Your application must provide acceptable proof of your experience. Please choose A (Yes) or B (No) for each of the following items to identify which of the following descriptions applies to you.
Select “Yes” or “No” to the following question(s).
4.
Medical Records Technician (Coder-Outpatient), GS-4
Experience or Education: None beyond basic requirements.
Assignment: Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Outpatient MRTs (Coder) select and assign codes from current versions of ICD Clinical Modification (CM), CPT, and HCPCS classification systems. MRTs (Coder) review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close 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.
Do you meet the basic requirements for the position listed above?
Experience or Education: None beyond basic requirements.
Assignment: Employees at this level serve as entry level MRTs (Coder) and receive close guidance from more experienced MRTs (Coder). Outpatient MRTs (Coder) select and assign codes from current versions of ICD Clinical Modification (CM), CPT, and HCPCS classification systems. MRTs (Coder) review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close 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.
Do you meet the basic requirements for the position listed above?
5.
Medical Records Technician (Coder-Outpatient), GS-5
Experience: One year of creditable experience equivalent to the next lower grade level;
OR,
Education: Successful completion of four years of education above high school leading to 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.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
NOTE: If utilizing education, must provide transcripts with conferred date
Experience: One year of creditable experience equivalent to the next lower grade level;
OR,
Education: Successful completion of four years of education above high school leading to 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.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Ability to use health information technology and software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
- Ability to navigate through and abstract pertinent information from health records.
- Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
- Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to outpatient/ambulatory surgery records, based on health record documentation.
- Knowledge of The Joint Commission requirements, Centers for Medicare and Medicaid Services (CMS), and/or health record documentation guidelines.
- Ability to manage priorities and coordinate work, in order to complete duties within required timeframes, and the ability to follow-up on pending issues.
NOTE: If utilizing education, must provide transcripts with conferred date
6.
Medical Records Technician (Coder-Outpatient), GS-6
Experience: One year of creditable experience equivalent to the next lower grade level.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Experience: One year of creditable experience equivalent to the next lower grade level.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Ability to analyze the health record to identify all pertinent diagnoses and procedures for outpatient coding and evaluate the adequacy of the documentation.
- 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.
- 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)).
- 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.
- Comprehensive knowledge of current classification systems, such as ICD CM, CPT, and HCPCS, and skill in applying said classifications to outpatient episodes of care, and/or inpatient professional services based on health record documentation.
- Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.
7.
Medical Records Technician (Coder-Outpatient), GS-7
Experience: One year of creditable experience equivalent to the next lower grade level.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Experience: One year of creditable experience equivalent to the next lower grade level.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Skill in applying current coding classifications to a variety of specialty care areas for outpatient episodes of care and/or inpatient professional services to accurately reflect service and care provided based on documentation in the health record.
- Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, ensuring the correct sequencing of diagnoses and/or procedures, and verifying the relationship between health record documentation and coder assignment.
- Ability to research and solve coding and documentation related issues.
- Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
- 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.
8.
Medical Records Technician (Coder-Outpatient), GS-8
Experience: One year of creditable experience equivalent to the next lower grade level.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Experience: One year of creditable experience equivalent to the next lower grade level.
**In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- 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 findings, 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.
Resume Reminder- Your resume must include the following information for each job listed:
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 Notification of Personnel Action
If you are claiming Facility, Agency, or Federal Employee Eligibility, you must submit a copy of your most recent (not more than 1 year old) Notification of Personnel Action, SF-50 (Not an award SF-50). Your SF-50 must include:
- 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
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 Notification of Personnel Action
If you are claiming Facility, Agency, or Federal Employee Eligibility, you must submit a copy of your most recent (not more than 1 year old) Notification of Personnel Action, SF-50 (Not an award SF-50). Your SF-50 must include:
- Position title, pay plan/series/grade
- Tenure code
- Position Occupied type of appointment (Competitive or Excepted)