- Position Title
- MED RECORDS TECHNICIAN (CODER)
- Agency
- Veterans Health Administration
- Announcement Number
- CBTA-12730130-25-NFG Opens in new window
- Open Period
- Monday, May 19, 2025 to Thursday, May 29, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Do you claim Veterans’ Preference?
Preferences
1.
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 the Medical Records Technician (Coder) - CDIS position with the VAMC. Your resume and responses you provide to the assessment questionnaire will be used to determine if you are among the best qualified for this position. Your responses are subject to verification. Please review your responses for accuracy before you submit your application. Select the appropriate answer to each of the following questions based on your current level of experience and/or education that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that answers are 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.
This position is open to the public.
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 spoken and written English as required by 38 U.S.C. 7402(d)?
Are you proficient in spoken and written English as required by 38 U.S.C. 7402(d)?
Grandfathering Provision.
All persons employed in VHA as a Medical Records Technician (Coder) - CDIS on the effective date of this qualification standard are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation. Employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:
(1) Such employees in an occupation that does not require a licensure/certification/ registration may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
(2) Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
(3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
All persons employed in VHA as a Medical Records Technician (Coder) - CDIS on the effective date of this qualification standard are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation. Employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:
(1) Such employees in an occupation that does not require a licensure/certification/ registration may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
(2) Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
(3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
2.
Experience and Education
Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
OR,
An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
OR,
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
NOTE: See the definitions section of this standard (paragraph 2g above) for a detailed definition of mastery level certification.
OR,
Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.
Do you possess the requirements above?
Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient);
OR,
An associate's degree or higher and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
OR,
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
NOTE: See the definitions section of this standard (paragraph 2g above) for a detailed definition of mastery level certification.
OR,
Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.
Do you possess the requirements above?
Grade Level Requirements - Please select the appropriate answer to each of the following questions based on your background and experience that demonstrates your ability to perform the duties of this position. When answering the questionnaire, remember that your experience and education are subject to verification by investigation.
3.
Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS-9 grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-9 position you must have served 52 weeks at the GS-8. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade.
Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment.
Do you meet this requirement?
Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment.
Do you meet this requirement?
Select “Yes” or “No” to the following question(s).
4.
Demonstrated Knowledge, Skills, and Abilities.
In addition to meeting the experience for the GS-08 level, you must possess the following Knowledge, Skills and Abilities.
i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
ii. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record.
iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
iv. Ability to establish and maintain strong verbal and written communication with providers.
v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
vi. Extensive knowledge of coding rules and regulations to include current 21 clinical classification systems (such as ICD, CPT, and HCPCS).
vii. Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.
viii. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
Do you possess the following Knowledge, Skills and Abilities above?
In addition to meeting the experience for the GS-08 level, you must possess the following Knowledge, Skills and Abilities.
i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
ii. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record.
iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
iv. Ability to establish and maintain strong verbal and written communication with providers.
v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
vi. Extensive knowledge of coding rules and regulations to include current 21 clinical classification systems (such as ICD, CPT, and HCPCS).
vii. Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.
viii. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
Do you possess the following Knowledge, Skills and Abilities above?
5.
GS-9 Requirement
One year of creditable experience equivalent to the next lower grade level of a GS-8
For GS-8 Some duties include, but are not limited to:
The Medical Records Technician (Coder)-GS-8 is at the journey level. 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.
Do you possess experience listed above?
One year of creditable experience equivalent to the next lower grade level of a GS-8
For GS-8 Some duties include, but are not limited to:
The Medical Records Technician (Coder)-GS-8 is at the journey level. 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.
Do you possess experience listed above?
6.
I certify that, to the best of my knowledge and belief, all of the information included in this questionnaire is true, correct and provided in good faith. I understand that if I make an intentional false statement, commit deception, or fraud in this application and its surrounding materials, or any document, or interview associated with the examination process, my eligibilities may be cancelled; I may be denied an appointment or I may be removed and debarred from Federal service (5 C.F.R. part 731). I understand that any information I give may be investigated and that responding "No", or providing no response to this item, will result in my not being considered for this position.
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 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.
Select “Yes” or “No” to the following question(s).
7.
Citizenship. Be a 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, of this part.)
Are you a citizen of the United States?
Are you a citizen of the United States?
8.
Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification.
Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), 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).
Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement 3 Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
Do you possess the required certification?
Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), 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).
Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement 3 Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
- (1) Mastery Level Certification through AHIMA or AAPC.
- (2) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Do you possess the required certification?