Summary This position is located in the Health Information Management (HIM) section at the Raymond G. Murphy VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
Duties
Major duties and responsibilities include but not limited to:
- 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 the ICD, CPT, and/or HCPCS.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code.
- Applies guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- Assists facility staff with documentation requirements.
- Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
- Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
- Uses a variety of computer applications in day-to-day activities and duties.
- Ensures current versions of all software applications are loaded and functional after any updates or changes.
- Reviews, analyzes and reports performance monitors for PCE, VERA and Non-VA Medical Care (purchased care) coding.
- Audit accurate and complete assignment of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records.
- Evaluation of clinical documentation.
- 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 analyze data.
- Facilitates improved overall quality, completeness and accuracy of coded data.
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
- Perform audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
- Collaboratively works with coding staff and clinical staff to provide support and education on coding issues.
- Provides training and education to coding and clinical staff.
- Research complex coding issues and participates in process improvements related to coding.
- Assists in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data.
- Provides advice and guidance on documentation and coding requirements.
- Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines and audit standards, and results in appropriate data capture and reimbursement.
- Analyze audit results and prepare summary feedback for individual coders and/or clinicians, making recommendations for improvement.
- Provide 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 with regular reports to the medical staff and management.
Work Schedule: Monday thru Friday, 8:00am to 4:30pm or 7:30am to 4:00pm
Telework: Ad-Hoc at the discretion of the manager.
Virtual: This is not a virtual position.
Functional Statement #: 00000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not AuthorizedQualifications
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 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).
- Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either below:
- Apprentice/Associate Level Certification through AHIMA or AAPC.
- Mastery Level Certification through AHIMA or AAPC.
- 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).
May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).
Grade Determinations: Medical Records Technician (Coder) Auditor, GS-9
- Experience. One year of creditable experience equivalent to the journey grade level GS-8 of a Medical Records Technician (Coder).
- Certification. Employees at this level must have a Mastery Level Certification through AHIMA or AAPC.
- Demonstrated Knowledge, Skills, and Abilities. In 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.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Physical Requirements: Sitting for extended periods. Ability to use computer keyboard and mouse efficiently. Sufficient vision to read electronic medical records and paper documents. Infrequent lifting of items weighing 10-20 pounds. Ability to concentrate and maintain confidentiality.Education Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.Requirements
- You must be a U.S. Citizen to apply for this job.
- To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's 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 interest. In 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.How you will be evaluated IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following Competencies for this position:
- Attention to Detail
- Customer Service
- Decision Making
- Flexibility
- Integrity/Honesty
- Interpersonal Skills
- Learning
- Reading Comprehension
- Self-Management
- Stress Tolerance
- Teamwork
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.How to apply Please read the entire announcement and all the instructions before you begin an application. To apply for this position, you must complete the initial online application, to include the initial online questionnaire and submission of the required documentation specified in the How to Apply and Required Documents section. The complete application package must be submitted by 11:59 PM (ET) on the closing date of the announcement to receive consideration. To preview the application questionnaire, click https://apply.usastaffing.gov/ViewQuestionnaire/13102203. The application process is as follows:
- To begin, click Apply Online to create a USA JOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents.
- Answer the questions presented in the application and attach all necessary supporting documentation.
- Click the Submit Application button prior to 11:59 PM (ET) on the announcement closing date, 11/13/2026.
- If you are required to complete any USA Hire Assessments, you will be notified after submitting your application. The notification will be provided in your application submission screen and via email. The notification will include your unique assessment access link to the USA Hire system and the completion deadline. Additionally, in USAJOBS you can click "Track this application" to return to your assessment completion notice.
- Access USA Hire using your unique assessment link. Access is granted through your USAJOBS login credentials.
- Review all instructions prior to beginning your assessments. You will have the opportunity to request a testing accommodation before beginning the assessments should you have a disability covered under the Rehabilitation Act of 1973 as amended.
- Set aside at least 3 hours to take the USA Hire Assessments; however, most applicants complete the assessments in less time. If you need to stop the assessments and continue later, you can re-use your unique assessment link. NOTE: Your responses to the USA Hire Assessments will be reused for one year (in most cases) from the date you complete an assessment. If future applications you submit require completion of the same assessments, your responses will be automatically reused.
Visit the USA Hire Applicant Resource Center for practice assessments and assessment preparation resources at https://support-usahire.opm.gov/hc/en-us.
To update your application, including supporting documentation: During the announcement open period, return to your USAJOBS account, find your application record, and click Edit my application. This option will no longer be available once the announcement has closed.
To view the announcement status or your application status: https://help.usajobs.gov/how-to. Your application status page is where you can view your application status, USA Hire assessment completion status, and review your notifications sent by the hiring agency regarding your application.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.Other information Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application. Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement. To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments.
Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.
During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.
This job opportunity announcement may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.
