Medical Records Technician
Department of Veterans Affairs - Cleveland, OH

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Vacancy Identification Number (VIN): 827097 (Please include on all documents)


Our mission: 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. YOU CAN MAKE A DIFFERENCE The Louis Stokes Cleveland VA Medical Center is a 673-bed tertiary healthcare facility which provides care to over 100,000 veterans in northern Ohio. We provide care through our main medical facility at the Wade Park campus, 13 community based outpatient clinics, and 3 vet centers. The medical center has been recognized for more programs of excellence than any other Veterans Affairs Medical Center. These programs of excellence include: Open Heart Surgery, Care of the Seriously Mentally Ill, Geriatric Evaluation and Management, Substance Abuse Care, Spinal Cord Injury Care, Medical Care of the Homeless, Domiciliary Care of the Homeless, Functional Electrical Stimulation, Advance Platform Technology, Primary Care Education, and Patient-Centered Specialty Care Education. We are a teaching hospital providing a full range of patient care services to Veterans with state-of-the art technology as well as medical education and research. Our main campus in Cleveland, OH has a full service ER for both general acute care and psychiatric care and a comprehensive reference clinical laboratory. With us, you will find a challenging, yet rewarding career experience.
  • Subject to a background/suitability investigation.
  • Designated and/or random drug testing may be required.
  • Occupational physical may be required.

DUTIES: There is a vacancy for a Medical Records Technician within the Inpatient Coding and Compliance Unit of the Health Information Management Section of Patient Care Administrative Services. The duty location for this vacancy is Wade Park. The duties and responsibilities are carried out throughout the medical center including all administrative and clinical areas involved with the service. Duties include but are not limited to:
  • Assisting management in planning, collecting, aggregating, analyzing and disseminating individual patient information and aggregate clinical data in order to create and complete a legal patient health record.
  • Reviewing and assigning codes to documented inpatient and outpatient encounters from the current version of several coding systems to include; the International Classification of Diseases Ninth Version Clinical Modification (ICD-9-CM), Diagnostic and Statistical Manual of Mental Disorders Fourth Version (DSM-IV), Current Procedural Terminology (CPT-4), and Healthcare Common Procedure Coding Systems (HCPCS). Identifying the principle diagnosis and principle procedure (when applicable) for every inpatient discharge. Identifying significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnostic Related Group (DRG) category.
  • Reviewing patient record before assigning pertinent codes and submitting the most accurate information relating to admissions, operations, procedures, and changes in treating specialty, diagnosis and disposition for each episode of hospitalization at the facility and public and private hospitals paid for by the facility. Reviewing documentation entered by clinicians and ancillary personnel and providing feedback.
  • Completing patient treatment file (PTF) for each admission by abstracting pertinent information, including clinical and demographic information and Evaluation and Management coding for Inpatient Professional Services.
  • Prioritizing assigned work based on established deadlines, and VACO mandates.
  • Assisting with the development of standardized, system-wide guidelines, procedures and compliance education materials for coding and abstracting. Assisting in developing training plans and orientation for new personnel and/or students assigned to the department.
  • Using VA proprietary software systems and Nursing Home Coding to access and enter information, manipulate and extract data in the medical center computer system. Using Microsoft Office applications, such as Microsoft Word, Excel, Power Point, etc., to prepare documents in order to graphically display data and to develop presentation materials.


Education and/or Experience: 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/Health Information Management (HIM) work.


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.


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:
  • 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.
  • 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.
  • 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.
  • 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.
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.


GS-4: None beyond basic requirements.

GS-5: Experience : In addition to the basic requirements, at least 1 year of experience equivalent to GS-4 level. OR

Education: Successful completion of a baccalaureate degree from an accredited college or university with a major field of study in medical record technology/health information technology or a related degree with courses related to medical record technology sufficient to evidence the core competencies identified.

GS-6: Experience: One year of experience comparable to the GS-5 level.

GS-7: Experience: One year of experience comparable to the GS-6 level.

Certification is desired (not required) at the GS-7 Grade Level: 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.

GS-8: One year of experience comparable to the GS-7 level.

When describing your experience please include your title, duties performed, and dates of employment. We will not make assumptions regarding your experience.

APPLICANTS PLEASE NOTE: Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement.) Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education. Applicants can verify accreditation at the following website: . All education claimed by applicants will be verified by the appointing agency accordingly.

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.

HOW YOU WILL BE EVALUATED: Your application will be reviewed to determine your qualifications. Please be sure your resume and supporting documentation clearly reflect your expertise related to the following competencies:
  • 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.
  • Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT.
  • 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.
  • Knowledge and experience in Evaluation and Management coding for Inpatient Professional Services.

BENEFITS: 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, 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 .

OTHER INFORMATION: Performance Based Interviewing (PBI) is utilized by our agency as part of our selection process. Please consult the PBI website at for further information.

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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...