The Medical Records Technician (MRT) Coder is responsible for performing a quality review of patient care documents and assigning codes specific to the type of care provided. For this assignment, Inpatient MRTs (Coders) select and assign codes from current versions of ICD-CM, PCS, and/or CPT and HCPCS classification systems for the full scope of inpatient facility and/or professional services.
The duties below are for the GS-0675-08, Journey Level. FUNCTIONS OR SCOPES OF PRACTICE INCLUDE BUT ARE NOT LIMITED TO: Utilize various computer applications to abstract records and assign codes to documented patient care records.
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 PCS/HCPCS codes for inpatient facility and/or professional services.
They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of inpatient settings and specialties. Has in-depth knowledge of: Medical terminology Anatomy & physiology Diseases Treatments Diagnostic tests And medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
Coding systems include: Current versions of the International Classification of Diseases (ICD) Procedure Coding System (PCS) And/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate: Diagnosis Operation Procedure Ancillary Evaluation and Management code to ensure ethical, accurate, and complete coding.
Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Maintains current knowledge of regulatory and policy requirements affecting coded information.
Independently reviews health record documentation to abstract all required: Medical Surgical Ancillary Demographic, social, and administrative data and queries clinical staff, as appropriate. Patient health records may be paper or electronic.
Independently assesses: Basic documentation requirements Coding requirements Accepted nomenclature and proper sequencing to obtain correct DRG Supports medical necessity Resolves encoder edits and ensures codes accurately reflect services rendered Ensures provider documentation supports the diagnoses and procedures coded. Directly consults with clinical staff to resolve issues related to conflicting or questionable clinical documentation.
Utilizes the facility computer system and software applications to: Code Abstract Record and transmit data to the national VA database in Austin Corrects any identified data errors Inconsistencies or audit findings in a timely manner to ensure acceptance in the national VA database within established timelines. Research references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.
Uses a variety of window-based 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 Ensures current versions of all software applications are loaded and functional after any updates or changes.
Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Other Duties as assigned. Work Schedule: M-F 8:00 am - 4:30 pm or as determined by the supervisor. Compressed/Flexible: This may be authorized at the supervisor's discretion. Telework: This is a Remote position. Virtual: This is not a virtual position.
Functional Statement #: 11975F, 11976F, 11977F, 11978F, 11979F
Experience and Education: Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, 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 (e.g., Medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Completion of an AHIMA-approved coding program, or other intensive coding training program of approximately one year or more that included courses in anatomy, 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 qualify 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 unpaid employment equivalent to an MRT (Coder). 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/.
leslie.doyle@va.gov · 928-445-4860 X6968
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $36409 – $72644/yr.
Yes, this position is fully remote.
This position requires a Other security clearance.
Applications close on 2026-10-13.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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