Medical Records Technician (Auditor-Inpatient Coder)

***This announcement closes 10/08/2026 -OR- once it reaches 25 applicants***

Major duties and responsibilities include but are not limited to:

• Applies comprehensive 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.
• Reviews assigned codes from the current version of several coding systems to include current versions of ICD CPT and/or HCPCS.
• Adheres to accepted coding practices guidelines and conventions when validating the most appropriate diagnosis operation procedure ancillary or evaluation and management (E/M) code to ensure ethical accurate and complete coding. Applies guidelines specific to certain diagnoses procedures and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• 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; provides technical support in the areas of regulations and policy coding requirements resident supervision reimbursement workload accepted nomenclature and proper sequencing.
• Audits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes MS-DRG POA status and discharge disposition values for inpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment.
• Analyzes audit results and prepares summary feedback for individual coders and/or clinicians making recommendations for improvement. Provides coding consultation to coders and/or clinicians related to coding and documentation questions.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Work Schedule: Monday - Friday from 8:00am-4:30pm
Recruitment/Relocation Incentives (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)
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 $144000 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 remote work ELIGIBLE and is currently exempted from return to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status.
Virtual: This is not a virtual position.
Functional Statement #: 000000
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 ( Effective May 7 2025 drivers licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation.
• 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 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.

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:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).
• Experience. One year of creditable experience that indicates knowledge of medical terminology anatomy physiology pathophysiology medical coding and the structure and format of a health record; OR
• Education. An associates 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); 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 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; OR
• 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 - Employees at this level must have a mastery level certification. Mastery Level Certification through AHIMA or AAPC. Current mastery level certifications include: Certified Coding Specialist (CCS) Certified Coding Specialist - Physician-based (CCS-P) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Professional Coder (CPC) Certified Outpatient Coder (COC) Certified Inpatient Coder (CIC).

Grade Determinations:

• GS-9 Experience Requirement: In addition to the basic requirements you must possess the following: One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder).
• Knowledge Skills and Abilities: In addition to the basic requirements certificate requirement and grade requirements; the candidates must be able to demonstrate the following knowledge skills and abilities.
  • Advanced knowledge of current coding classification systems such as ICD CPT and HCPCS for the subspecialty being assigned (outpatient inpatient outpatient and inpatient combined).
  • Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  • Ability to review coded data and supporting documentation to identify adherence to applicable standards coding conventions and guidelines and documentation requirements.
  • Ability to format and present audit results identify trends and provide guidance to improve accuracy.
  • Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

Preferred Experience: Three or more years of experience coding and or leading a coding team.

Reference: For more information on this qualification standard please visit full performance level of this vacancy is GS-9.

Physical Requirements: See VA Directive and Handbook 5019 Employee Occupational Health Service.