Medical Records Technician (Coder - Inpatient)

Medical Record Technicians (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, multi-specialty clinics, and specialty centers. MRTs apply knowledge of medical record content, terminology, anatomy, diseases processes, and official coding guidelines to assign codes to the most basic and routine inpatient facility and/or professional services.

Total Rewards of a Allied Health Professional Duties of the position will vary dependent on grade for which selected, but may include: Selecting and assigning codes from the current versions of the International Classification of Diseases (ICD), Clinical Modification (CM), and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding. Learn to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions, and policy Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin, identified errors are reviewed with a senior coder or the supervisor and corrections made as directed Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; develops use of health record applications as well as the encoder product suite Maintains current knowledge of regulatory and policy requirements affecting coded information Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment works within a team environment; supporting peers in meeting goals and deadlines, coping with frequently changing projects and deadlines Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission, codes the admission diagnosis for use by unit staff utilizing the current version of the ICD coding system Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record Establishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of service provided. Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters Work Schedule: 0600-1800 (Flexible) Monday-Friday Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). 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: Available - Ad Hoc Virtual: This is not a virtual position. Functional Statement #: 30292F | 30291F | 30290F | 30289F | 30288F Permanent Change of Station (PCS): Not Authorized

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 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.