Medical Records Technician (Coder-Outpatient)

Department: Department of Veterans Affairs

Location(s): Anywhere in the U.S. (remote job), United States

Salary Range: $63203 - $82170 Per Year

Job Summary: Medical Record Technicians (Coder) at the San Diego VA Medical Center are skilled in classifying medical data from patient health records in a hospital setting. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in medical terminology. Although this position is telework eligible, incumbent may be required to return to the office permanently at a later date.

Major Duties:

Total Rewards of a Allied Health Professional Duties include but are not limited to: Assigns codes to documented patient care encounters covering the full range of health care services provided by the VAMC. Applies advanced knowledge of medical terminology, anatomy and 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. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding. 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 to completely and accurately reflect the patient care provided Utilizes the facility computer system and software applications to correctly code. Uses a variety of computer applications in day to day activities and duties. Works within a team environment; supports peers in meeting goals and deadlines. Identifies the principal diagnosis and principal procedure (when applicable) for every outpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Conducts reviews of codes abstracted for outpatient encounters identified by the VERA committee. Codes outpatient professional fee services for identified outpatient admissions. Codes all outpatient procedures reported in the Surgical Package of the VistA hospital system. Updates codes for current outpatient and Contract Nursing Home admissions. Reviews and codes assigned fee service Care in the Community outpatient encounters. Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Work Schedule: 0700-1800 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) 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: This position is telework eligible but may be required to return to the office permanently at a later date. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized

Qualifications: Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. BASIC REQUIREMENTS: 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.) 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 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; 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 4 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 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). 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: MRT (Coder) 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 Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists. Grandfathering Provision: May Apply. Medical Records Technician (Coder-Outpatient/Inpatient), GS-8: Grade Determinations: In addition to meeting the basic requirements, the following experience and/or education AND all the knowledge, skills and abilities (KSAs) must be met for the grade. Experience. In addition to meeting basic qualifications, you must have one year of creditable experience equivalent to the next lower grade level AND demonstrate the following Knowledge, Skills and Abilities (KSAs): Knowledge Skills and Abilities (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/or inpatient professional fee services coding. 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 Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-08. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

How to Apply: 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 11/14/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12819744. 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.

Application Deadline: 2025-11-14