Medical Records Technician (Coder Inpatient/Outpatient)

JobSummary

This position is located in the Health Information Management (HIM) section of the Business Office at the North Florida/South Georgia VA Healthcare System. MRTs (Coders) 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, multispecialty clinics, and specialty centers. Please read the duties section of this announcement for further information on remote work status.

LowGrade

4

HighGrade

8

PromotionPotential

8

SubAgencyName

Malcom Randall Department of Veterans Affairs Medical Center

OrganizationCodes

VA/VATA

Relocation

False

HiringPath

• fed-internal-search
• public

MCOTags

AgencyMarketingStatement

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans? The North Florida/South Georgia Veterans Health System consists of 2 medical centers, 3 large multi-specialty outpatient clinics and 8 small community-based primary care outpatient clinics. The Malcom Randall VA Medical Center (VAMC) in Gainesville is a tertiary care facility that is also an active teaching hospital, with an extensive array of specialty services. The Malcom Randall VAMC combines a full range of patient care services with state-of-the-art technology that is enhanced and supported through education and research. Facilities include: Malcom Randall VAMC in Gainesville, Lake City VAMC and Jacksonville Navy VAMC; multi-specialty outpatient clinics in Jacksonville, Tallahassee, and The Villages, Florida; and community-based outpatient clinics (CBOCs) in Lake City, Marianna, Middleburg, Ocala, Palatka, Perry, and St. Augustine, Florida; and St. Mary's, Valdosta, and Waycross, Georgia. The VA North Florida/South Georgia Veterans Health System is a part of Veterans in the VA Sunshine Health Care Network, Veterans Integrated Service Network 8 (VISN 8), which includes medical centers and clinics in Florida, Georgia, and the Caribbean.

TravelCode

0

ApplyOnlineUrl

https://apply.usastaffing.gov/Application/Apply

DetailStatusUrl

https://apply.usastaffing.gov/Application/ApplicationStatus

MajorDuties

• PLEASE NOTE: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S. Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements. Any selected candidate must live within 50 miles of a VA Medical Center. Duties may include, but are not limited to, the following: Assigns codes to documented patient care encounters (inpatients and outpatient) covering the full range of health care services provided by NF/SG VHS. Applies advanced 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. Selects and assigns codes from the current version of several coding systems to include the International Classification of Disease-Clinical modification and Procedure classification system (ICD-9-CM, ICD-10 CM, AND ICD-10 PCS), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by NF/SG VHS. Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Provides technical support in the areas of regulation and policy, coding requirements, resident supervision, reimbursement, workload accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnosis and procedure coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient record. Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established time lines. Works within a team environment; supports peers in meeting goals and deadlines. Maintains a record of work accomplishments and backlogs providing a daily report to the coding manager. Work Schedule: Full Time, Monday-Friday, 8:00am-4:30pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Yes-This position is telework eligible. This position will be reviewed annually and does not imply permanent telework status. Virtual: This is not a virtual position. Functional Statement #: 50187F, 50188F, 50192F, 50191F, 50193F Permanent Change of Station (PCS): Not Authorized

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/. Medical Records Technician (Coder-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. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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.). 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 inpatient and outpatient episodes of care based on health record documentation. Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues. Medical Records Technician (Coder-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. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Demonstrated Knowledge, Skills, and Abilities. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to 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 HIPAA). iv. Ability to accurately apply the ICD CM and PCS Official Conventions and Guidelines for Coding and Reporting to various coding scenarios. v. Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) and PCS, CPT, and HCPCS, and skill in applying said classifications to inpatient records based on health record documentation. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG). Medical Records Technician (Coder-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. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Demonstrated Knowledge, Skills, and Abilities. Skill in applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record. ii. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code 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. ***Please see additional grade level requirements under Education and Additional Information sections.***

Requirements

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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. 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.

Evaluations

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. 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.

HowToApply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 04/13/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12919099. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

WhatToExpectNext

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made. You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

RequiredDocuments

To apply for this position, you must provide a complete Application Package which includes: Resume Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field. Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field. The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc. Cover Letter Resume/CV to include longer than 2-pages - See JOB ANNOUNCEMENT- Required Documents Box. Professional Certification Resume SF-50/ Notification of Personnel Action Transcript

Benefits

BenefitsUrl

http://www.vacareers.va.gov/why-choose-va/benefits/index.asp

OtherInformation

Medical Records Technician (Coder-Inpatient), GS-8 (Full Performance Level) Experience. One year of creditable experience equivalent to the next lower grade level. Assignment. This is the journey level for this assignment. Inpatient MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Demonstrated Knowledge, Skills, and Abilities. Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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. Ability to accurately perform the full scope of inpatient 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. References: VA Handbook 5005/122 Part II, Appendix G-57, Medical Record Technician Qualification Standard. 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. 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.

KeyRequirements

WithinArea

False

CommuteDistance

0

ServiceType

02

AnnouncementClosingType

01

AgencyContactEmail

Hannah.Henderson@va.gov

AgencyContactPhone

813-816-7155 X100152

SecurityClearance

Not Required

DrugTestRequired

False

PositionSensitivitiy

Non-sensitive (NS)/Low Risk

AdjudicationType

• Suitability/Fitness