This position is located in the Health Information Management (HIM) section at the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). Medical Record Technician (Coder Inpatient) 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, multispecialty clinics, and specialty centers.
Total Rewards of a Allied Health Professional Medical Record Technician (Coder Inpatient) primary duties include but are not limited to: Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise.
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. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
Insures provider documentation is complete and supports the diagnoses and procedures coded. Reports incorrect documentation or codes in the electronic patient health record. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program. Codes inpatient professional fee services for identified inpatient admissions.
Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
Codes all inpatient procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
Reviews and codes assigned fee service Care in the Community inpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, military facilities, etc. Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Work Schedule: Monday thru Friday 8:00am to 4:30pm. Compressed/Flexible: Telework: Not Authorized Virtual: This is not a virtual position.
Functional Statement #: 21765F, 21764F, 21763F, 21762F, 21761F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized
****GS-8. One year of creditable experience equivalent to the next lower grade level. 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.
Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/ or assigning CPT/HCPCS codes for inpatient professional services.
GS-8 KSAs: 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.
EDUCATION: GS-04 - 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); GS-05 - Experience of 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. 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/.
Michael.Markham@va.gov · 254-778-4811 X150406
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $36409 – $72644/yr.
Applications close on 2026-10-15.
This position is open under the 'Fed Transition' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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