Supervisory Medical Records Technician (Inpatient Coder)

Summary

This position is in the Health Information Management Section (HIMS) of the Health Administration Service Line at the Puget Sound VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics - and specialty centers.

Qualifications

To qualify for this position - applicants must meet all requirements within 30 days of the closing date of this announcement.

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 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 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: Apprentice/Associate Level Certification through AHIMA or AAPC
• Mastery Level Certification through AHIMA or AAPC
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• 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
• Loss of Credential: Following initial certification - credentials must be maintained through rigorous continuing education - ensuring the highest level of competency for employers and consumers
• An employee in this occupation who fails to maintain the required certification must be removed from the occupation - which may result in termination of employment
• At the discretion of the appointing official - an employee may be reassigned to another occupation for which he/she qualifies - if a placement opportunity exists
• Grade Determinations: Supervisory Medical Records Technician (Coder) - GS-10 Supervisory coder assignments can be established for any of the coder subspecialties (outpatient - inpatient - outpatient and inpatient combined)
• The subspecialty will be reflected in the title - e.g. - Supervisory MRT (Coder Outpatient) Experience: One year of creditable experience equivalent to the next lower grade level
• Certification: Employees at this level must have a mastery level certification
• Reference: For more information on this qualification standard - please visit
• The full performance level of this vacancy is GS-10
• Physical Requirements: There are no physical requirements for this occupation per OCHCO Communications email to VA Handbook 5019 - updated on 4/17/2026.

Duties

• This position has Return to Office (RTO) mid-term extension (NTE 8/31/2027)
• Remote work is currently authorized
• however - candidates may be subject to return to office in the event policy changes or the exemption is not extended
• Total Rewards of a Allied Health Professional 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
• Duties will include: Functions: 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
• Selects and assigns codes from the current version of several coding systems
• Adheres to accepted coding practices - guidelines and conventions
• Applies codes based on guidelines specific to certain diagnoses - procedures - and other criteria (in inpatient and outpatient settings)
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC
• Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs
• Performs a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• 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
• Insures provider documentation is complete and supports the diagnoses and procedures coded
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data
• Reports incorrect documentation or codes in the electronic patient health record
• Develops performance standards and conducts performance evaluations for subordinate staff
• Interviews new employees - recommends selection - and carries out training and development of reassignments - awards or disciplinary action
• Approves leave schedules
• Implements provisions of EEO programs to ensure fair and equal treatment for all employees
• Keeps employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concerns
• Schedules the sequence of work and operations on a weekly - monthly and quarterly basis to assure even workflow and distribution - expeditious handling of priorities and the meeting of deadlines
• Revises schedules/assignments to meet changes in workload considering peak loads - availability of manpower and time limits
• Makes changes in organization and assignment of duties to provide improvements - promote job satisfaction and increase productivity
• Prepares workload and production reports
• reports on operations and problems encountered
• and presents proposed requests for resource needs based on past experience - anticipated staffing - equipment - and space
• Makes assignments that are equitable among employees
• Other duties as assigned - as related to the needs of the program
• Work Schedule: Monday-Friday - 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)
• 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: Not Available Virtual: This is not a virtual position
• Permanent Change of Station (PCS): Not Authorized