Medical Records Technician

Summary This position is located in the Health Information Management (HIM) Section of the Health Administration Services Department at the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, IL. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. Responsibilities Total Rewards of a Allied Health Professional Functions of this position include, but are not limited to the following: 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. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided. 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. Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyzes data. Performs audits of coded data, developing criteria, collecting data, graphing, trending, and analyzing results, creating reports, and communicating in writing and/or in person to appropriate leadership and groups. 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 Work Schedule: Monday-Friday, 0730-1600 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) 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: Ad-hoc telework available Virtual: This is not a virtual position. Functional Statement #: 07790F Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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, 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. Qualifications 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. Experience and Education 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 records. OR Education. An associate's 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 4 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. 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. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f) May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Medical Records Technician (Coder) Auditor, GS-9 Auditor assignments can be established for any of the coder subspecialties (outpatient, inpatient, or outpatient and inpatient combined). The subspecialty will be reflected in the title, e.g., MRT (Coder) Auditor (Outpatient). Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder). Certification. Employees at this level must have a mastery level certification. NOTE: See paragraph 2g for a detailed definition of mastery level certification. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, 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). Reference: For more information on this qualification standard, please visit The full performance level of this vacancy is GS-9. 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: Additional Information 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. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.