Medical Record Technician (Coder)

Department Of Veterans Affairs Cleveland , OH 44114

Posted 2 months ago

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The VA Northeast Ohio Healthcare System is recruiting for a Medical Record Technician (Coder). The Medical Record Technician (Coder) will function in Heath Information Management Section in Patient Care Administrative Service.

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  • Assigning codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the Medical Center.

  • Applying 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.

  • Assigning codes from the current version of several coding systems to include current versions of the International Classification of Disease (ICD-CM and ICD-10 PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

  • Adhering to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.

  • Applying codes based on guidelines specific to certain diagnosis, procedures, and other criteria (inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program.

  • Monitoring changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the Medical Center.

  • Performing a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

  • Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided.

  • Searching the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.

  • Using a variety of windows based applications such as Outlook, Excel, Word, and Access.

Work Schedule: Monday

  • Friday, 8:00 a.m.

  • 4:30 p.m.

Telework: Available

Virtual: Available at the discretion of the Medical Center

Financial Disclosure Report: Not Required

Travel Required

Not required

Supervisory status


Promotion Potential


  • Job family (Series)

0675 Medical Records Technician

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  • Requirements



Conditions of Employment

  • You must be a U.S. Citizen to apply for this job

  • Designated and/or random drug testing may be required

  • Selective Service Registration is required for males born after 12/31/1959

  • You may be required to serve a probationary period

  • Subject to a background/security investigation

  • Must be proficient in written and spoken English

  • Selected applicants will be required to complete an online onboarding process


Basic Requirements:

  • Citizenship. Must be a Citizen of the United States.

  • English Language Proficiency. Must be proficient in spoken and written English.

  • Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health record; OR

  • Education. An associate's degree from an accredited college of 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: (a) 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; (b) 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 an MRT (Coder). (TRANSCRIPTS REQUIRED)

Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:

  • Apprentice/Associate Level Certification through AHIMA or AAPC.

  • Mastery Level Certification through AHIMA or AAPC.

  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.

GS-8: Full Performance Level

Experience. One year of creditable experience equivalent to the next lower grade level.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

  • Ability to analyze the health record to identify all pertinent diagnoses and procedures for 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 outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.

  • 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.

Reference: VA Handbook 5005, Part II, Appendix G57, Medical Record Technician Coder Qualification Standard, GS-675, available in the local Human Resources Office.

The full performance level of this vacancy is GS-8.

Physical Requirements:Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices.


IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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: 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:

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Medical Record Technician (Coder)

Department Of Veterans Affairs