Medical Records Technician (Coder)
Department Of Veterans Affairs - Lexington, KY

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Vacancy Identification Number (VIN): 830256


(See " Required Documents " section below)



Tour of duty: Monday through Friday, 8:00 A.M. - 4:30 P.M.

To fulfill President Lincoln's promise - "To care for him who shall have borne the battle, and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans.

How would you like to become a part of a team providing compassionate care to Veterans?

As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries.

NOTE: The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-6 to GS-8. The Professional Standards Board (a peer-review group) will review the selected candidate’s education and experience and recommend the grade and step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate.

Special Employment Consideration: VA encourages persons with disabilities to apply.

The incumbent for this position may be eligible to apply for the Education Debt Reduction Program. Please contact Human Resources at this medical center and speak with the Education Debt Reduction Program Coordinator for additional information.


  • U. S. Citizenship
  • Background and-or Security Investigation required
  • You will be subject to a review by a Professional Standards Board.
  • English Language Proficiency required
  • Designated and-or Random Drug Testing required
The incumbent serves as a Medical Records Technician (MRT) - Coder in the Veterans Equitable Resource Allocation (VERA) program, which is aligned under the Medical Center Director. T he primary purpose of this position is to validate and assign appropriate codes that reflect the treatment provided to patients. The principal focus of this position will be coding outpatient encounters but may include inpatient encounters should the need arise.

The incumbent is responsible for reviewing the electronic medical record to ensure the most appropriate codes are assigned. The incumbent is responsible for entering information into the appropriate software package(s) and maintaining a control system to track any changes.

A primary function of this position is to work closely with the members of the health care team, particularly the providers , to provide support and technical guidance relative to the selection of the best code(s) possible. The incumbent is expected to interact with the providers on a face-to-face basis and will spend a portion of their time located in the clinics as an embedded part of the care team.

Note - For candidates qualifying at the GS-7 Level:
Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the MRT will possess the knowledge of, and skill in applying, a standardized body of rules, procedures, and operations sufficient to:

  • Code diagnostic and operative/procedural information;
  • Organize patient charts to search and extract medical data;
  • Review records for completeness, accuracy, and compliance with applicable medical facility and accreditation

  • prepare correspondence, reports, and other material; and
  • determine the probability of payment from various sources (e.g., Medicare, Medicaid).
The GS-7 level MRT will be assigned progressively more challenging work assignments throughout his/her initial year within the position. By the completion of the initial year, the MRT will be expected to code all encounter types and attain the knowledge of, and skill in applying, a standardized body of rules, procedures, and operations sufficient to:

  • code complicated medical records that are difficult to classify;
  • analyze medical records, maintain special registries, perform quality assurance, compile statistical data, and
release medical information;

  • collect and organize data for reports, audits, and/or research projects;
  • extract data for statistical and other reports.
The preferred candidate will have inpatient and outpatient coding experience, as well as experience with Diagnosis-related group ( DRG) coding.

a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified candidates in accordance with chapter 3, section A, paragraph 3g, this part.)

b. Experience and Education

(1) Experience. Two years of experience that demonstrates the applicant’s ability to perform the work, or provides familiarity with the work. Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT work.


(2) Education. Successful completion of an associate’s degree with a major field of study in medical record technology/health information technology, which was accredited by the American Health Information Management Association (AHIMA) at the time the program was completed.


(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate in this provision for combining education and experience:

(a) Successful completion of an associate’s degree in a field of study other than medical records/health information will substitute for 18 months of the required experience.

(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 1 year of experience.

(c) Successful completion of a post-high school course of study in medical record technology, which includes courses in anatomy, physiology, and medical record techniques and procedures, may substitute on a month-for-month basis for up to 1 year of experience.

(d) Successful completion of post-high school courses for medical administrative personnel, obtained in a closely supervised training program given by the Armed Forces, may be substituted for experience on a month-for-month basis for up to 6 months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures.


Foreign Education: To be creditable, education completed outside the U.S. must have been submitted to a private organization that specializes in the interpretation of foreign educational credentials and such education must have been deemed at least equivalent to that gained in conventional U.S. programs.

Completion of appropriate training such as in-service training programs, on the job training, training acquired while in the Armed Forces, government sponsored developmental training programs, and/or training under physicians certified in the functional area will be allowed on a month-for-month basis through the GS-5 level.


a. Definitions

(1) Creditable Experience

(a) Knowledge of Current Medical Record Technology. To be creditable, t he experience must have required the use of knowledge, skills, abilities, and other characteristics (also referred to as “core competencies”) associated with current health information or medical record technology and/or cancer registry practice.

(b) Quality of Experience. Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be at a level comparable to medical record technology experience at the next lower grade level.

(c) Part-Time Experience. Part-time experience as a professional medical record technician is credited according to its relationship to a full-time work week. For example, a medical record technician would receive 1 week of full-time credit for each 2 weeks of half-time work.

(d) Specialized Areas for Medical Record Technicians

Medical Coders analyze and abstract medical record data and assign codes using clinical classification systems. Medical coding requires independent judgment based on medical record documentation and personal coding knowledge and skill. Certification is offered by AHIMA as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or Registered Health Information Technician (RHIT). Certification is offered by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder Apprentice (CPC-A), Certified Professional Coder-Hospital Apprentice (CPC-H-A), Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H) and is highly desired at the higher grade levels.

Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.


Experience. One year of experience comparable to the next lower level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:

Assignments. Employees at this level typically work in any specialty area of medical record/health information. In some instances, they may be assigned lead or supervisory positions when the highest level of non-supervisory MRT work is at a lower level. They receive little guidance from more experienced staff members.

NOTE: In order to be considered a leader, the employee must be responsible to his/her supervisor for ensuring that the work assignments of the other employees of the team are carried out by successfully performing a range of duties which include such duties as distributing and balancing workload, monitoring the status and progress of work, instructing and answering employee questions, checking employee work, amending or rejecting work not meeting standards, approving leave for a few hours or for emergencies, resolving simple, informal complaints, etc.


Experience. One year of experience comparable to the next lower grade level and must fully meet the KSAs at that level including those for tumor registry or coder assignments if applicable. In addition, the candidate must demonstrate the following KSAs:

Assignments. Employees at this level will be assigned to a specific area of medical record/health information (tumor registry, medical coding, or medical records). They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies are described for each type of assignment as follows.

Medical Record Technician Coding Positions. Medical coding assignments at this grade level represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/ health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level. Since coding rules are specific to individual classification systems, knowledge of coding systems other than the one utilized in the position for which the individual is being boarded does not automatically meet the requirements of the position. Generally, to receive credit for experience, the coder should have performed the type of coding specified as a significant portion of duties on a regular and recurring basis, and provide evidence of the core competencies identified.


Experience. One year of experience comparable to the next lower grade level for the appropriate assignment area and must fully meet the KSAs at that level.

Assignments. Employees at this grade level will be assigned to a specific area of medical record/health information, e.g., tumor registry, medical coding, or medical records. They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies for the different assignments are listed with the assignment.

Medical Record Technician (Medical Coder) Positions. This is considered to be the full performance level for this assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:


References: VA Handbook 5005, Part II, Appendix G35, MEDICAL RECORDS TECHNICIAN qualification standard, dated March 2006. The VA Handbook 5005 is available in the local Human Resources Office.

Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. You may also be evaluated based upon the question responses you provide during a structured interview. In responding to structured interview questions you should be sure to cite specific examples of experience, explain exactly what you did, and the outcome.

KNOWLEDGE, SKILLS AND ABILITIES: Applicants must possess training and experience that clearly demonstrate they possess the following knowledge, skills and abilities. This training or experience must be reflected by descriptions of your experience in your resume and/or supporting documentation.


1. Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record;

2. Ability to navigate efficiently through the paper and electronic medical record to find needed information;

3. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and ability to use judgment in completing assignments with incomplete or inadequate guidelines;

4 . If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable;

5. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA);

6. If assigned to a tumor registry position, ability to apply guidelines and standards for the maintenance of an approved tumor registry; and

7. If assigned to a medical coding position, comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), and skill in applying coding knowledge.


1. Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying coding knowledge to a wide range of specialty areas;

2. Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements;

3. Ability to communicate with clinical staff on coding and documentation issues such as recording inpatient and outpatient diagnoses and procedures, the use of encounter forms, the correct sequencing of diagnoses/ procedures, and/or the relationship between health care documentation and code assignment;

4. Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and

5. Skill in reviewing and correcting system or processing errors, reviewing transmission reports, and ensuring all assigned episodes are complete and accurate as appropriate to the duties assigned.


1. Ability to analyze the medical 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 medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;

2. Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT; and

3. Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, diagnostic studies and procedures, outpatient encounters, and inpatient professional fees for a highly diversified range of specialties and subspecialties, such as orthopedics, neurosurgery, cardiology, gastroenterology, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.

Veterans' Preference:
When applying for Federal Jobs, eligible Veterans should claim preference on their application or résumé. Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must complete an SF 15, Application for 10-Point Veteran Preference. Veterans who are still in the service may be granted tentative preference on the basis of information contained in their applications, but they must produce a DD Form 214 or other proof prior to appointment to document entitlement to preference. For more information on Veterans' Preference, please visit .

Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, thrift savings plan, and participation in the Federal Employees Retirement System. In addition to traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life. For more information please visit us at .

This position will be filled on a full-time permanent basis.

A one year probationary period will be required.

Salary is dependent upon education and experience, and will be determined by a Professional Standards Board.

This position is in the Excepted Service and does not confer competitive status.

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employees credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave.

If additional vacancies for this position occur within 90 days, this announcement may be used without reannouncement.

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The United States Department of Veterans Affairs (VA) is a government-run military veteran benefit system with Cabinet-level status. It is...