Medical Records Technician (Coder)

• Duties and responsibilities within this position range from Entry Level (GS-4) with close supervision, to Journey Level (GS-8) with the full scope of inpatient and outpatient coding duties. At the Entry Level, MRTs (Coder) will perform the following duties under close supervision from more experienced MRTs (Coder): Select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate. Use various computer applications to abstract records, assign codes, and record and transmit data. Ensure audit findings have been corrected and refiled. At the Journey Level, MRTs (Coder) will perform the following duties: Select and assign codes from current versions of ICD-10-CM, ICD-10-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-10-CM and ICD-10-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-10-CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. 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. Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of ambulatory/inpatient settings and specialties. Consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned, and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected, when necessary. Correct any identified data errors or inconsistencies. Ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data. Work Schedule: Monday-Friday, 0800-1630 Telework: Not applicable, this is a remote position. Virtual: This is not a virtual position. Functional Statement #: PD000000 Relocation/Recruitment Incentives: Not Authorized 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/.

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.

Required Documents

To apply for this position, you must provide a complete Application Package which includes: Long-form resume/Curriculum vitae (CV) Professional Certification 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.

DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) Long-form resume/Curriculum vitae (CV) Professional Certification Separation Notice (RIF) SF-15 SF-50/ Notification of Personnel Action Transcript