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MEDICAL RECORDS TECHNICIAN CODER, In Patient/Out Patient (Virtual/Remote Positions)

Company: Department of Veterans Affairs
Location: Salt Lake City
Posted on: June 12, 2021

Job Description:

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  • Duties




The VISN 19 Consolidated Coding Unit (CCU) Medical Record Technician (MRT) is located within the Business Office Support Services (BOSS), Health Information Management (HIM) section, within VISN 19, Rocky Mountain VA Network. VISN 19 CCU is recruiting for multiple virtual/remote positions. Salary will be based on geographical location of selectee.

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The VISN Consolidated Coding Unit provides coding support for the eight facilities within VISN 19 and other VA facilities. This entails coding multiple types of encounters from varied services and specialties. The MRT must be flexible in work assignment and well versed in accessing CPRS for multiple facilities. Documentation will vary for each facility. Duties range from the GS-04 (Entry Level) up to the GS-08 (Full Performance Level), depending on qualifications. Duties include but are not limited to the following:

  • Completes Inpatient, Outpatient, and Surgery Coding.
  • Apply laws/regulations on the confidentiality of health information (e.g., Privacy act, Freedom of Information Act, Health Insurance
  • Portability and Accountability Act (HIPPA)
  • Perform inpatient or outpatient coding duties or a combination
  • Conduct comprehensive review of health records to ensure complete data capture
  • Apply knowledge of current coding systems such as ICD 10 CM, ICD 10 PCS, CPT, and HCPCS
  • Apply 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
  • Interpret and apply regulatory policy
  • Researches, abstracts, and corrects data as required to solve complex questions related to coding

Preferred Experience

  • Comprehensive knowledge of classification systems, including ICD-10 (International Classification of Diseases), CPT (Current Procedure Technology) , and HCPCS (Healthcare Common Procedure Coding System)
  • Preferred applicant will have at least 5 years' experience in coding, including inpatient, outpatient, surgical and professional fees, in a variety of specialties.
  • Preferred RHIT, CCS, or CPC
  • Two (2) or more years VA Experience as an MRT Coder.
  • Proficiency in Nuance applications (CCM, VIP Workplace, Clintegrity)
  • Previous telework experience
  • Previous experience as a virtual employee

Work Schedule: Full Time, Permanent, Monday thru Friday. 0800-1630.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



Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens)

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 be possess an Apprentice/Associate Level Certification through AHIMA or AAPC.

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.

Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:

  • Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
  • Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
  • MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
  • MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
  • Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.

English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).

Grade Determinations:GS08

Experience. One year of creditable experience equivalent to the GS07 level that is directly related to this position. Experience includes:

  • Applying current coding classifications to a variety of inpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
  • Communicating with clinical staff for specific coding and documentation issues, such as recording diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
  • Researching and solving coding and documentation related issues.
  • Reviewing and correcting system or processing errors and ensuring all assigned work is complete.
  • Abstracting, assigning, and sequencing codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators, to obtain correct MS-DRG.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, you must demonstrate the following:

  • Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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 inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
  • 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.


The full performance level of this vacancy is GS08. The actual grade at which an applicant may be selected for this vacancy is GS08

Physical Requirements: This position is mostly sedentary with some walking and carrying light items such as documents and/or files.


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:

Keywords: Department of Veterans Affairs, Salt Lake City , MEDICAL RECORDS TECHNICIAN CODER, In Patient/Out Patient (Virtual/Remote Positions), Other , Salt Lake City, Utah

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