Sup Med Records Technician (Coder)

Summary

This position is located in the Health Information Management (HIM) section at the Edward Hines Jr. VA Hospital. 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.

Duties

• Coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.
• 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 to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management 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 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.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
• Ensures current versions of all software applications are loaded and functional after any updates or changes.
• Works within a team environment; supports staff in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• 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.
• Coordinates with other Service representatives on matters concerning health record documentation and coding, as well as changes and challenges that may have an impact on other Units or Services.
• Keeps abreast of all regulations and guidelines governing the coding section, ensuring that staff supervised is educated as needed.
• Ensures that regulatory guidelines and current coding conventions are followed.
• Other duties as assigned.
• Work Schedule: Monday
• 4:00pm. Tour of Duty varies based on the needs of the service. Telework: Ad-hoc telework eligibility may be authorized. Virtual: This is not a virtual position. Functional Statement #: 02803F. Relocation/Recruitment Incentives: Not Authorized.

Requirements

• 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• 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.
• Must pass pre-employment physical examination.
• 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
• 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.

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: http://ope.ed.gov/accreditation/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Grandfathering Provision. All persons employed in VHA as a MRT (ROI) on the effective date of this qualification standard are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation. 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:(1) Such employees in an occupation that does not require a licensure/certification/ registration may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.(2) Employees 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.(3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

Required Documents

• To apply for this position, you must provide a complete Application Package which includes:
• Professional Certification Resume
• SF-50/ Notification of Personnel Action Transcript Special Note for
• Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume
• This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.
• Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.
• The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former
• Federal employees), etc. Cover Letter
• DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) License Other (1) Professional Certification Resume
• SF-50/ Notification of Personnel Action Transcript
• Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below.Effective
• September 29, 2025, HR office staff must ensure the two-page resume limit is clearly stated in
• USAS in the "How to
• Apply" section of all applicable
• JOAs (identified in item 3, Scope, of this bulletin), by using the below language: Beginning
• September 27, 2025, Federal agencies will only accept resumes up to two pages in length to comply with the Merit Hiring
• Resumes longer than two pages will result in ineligibility for further consideration for the position.
• USAJOBS will not allow you to upload or build resumes longer than two pages, and you will need to update the resumes in your profile before applying for a job.
• Resumes should include information relevant to the knowledge, skills, abilities, and competencies of the position to which you are applying.
• VA is unable to make assumptions about qualifications if not clearly listed.
• Resumes must be legible so they can be reviewed for eligibility, minimum qualifications and other position requirements listed in the job announcement.
• Your resume must be 5MB or less.
• We recommend saving and uploading your resume as a
• PDF to maintain formatting and number of pages. We also accept
• GIF, JPG, JPEG, PNG, RTF, TXT, PDF, ODT or
• Word (DOC or
• DOCX). We do not accept
• PDF portfolio files. We recommend using a sans-serif font size like
• Lato, if available. Other widely available options are
• Calibri, Helvetica, Arial, Verdana, Open San Source Sans
• Pro, Roboto or Noro
• Sans. Make your page margins 0.5 inches. Consider using 14-point size font for titles and 10-point for the main text in your resume. The resume builder can help you create a resume using these recommendations and uses the information in your
• USAJOBS profile to help you get started. Helpful Hints for Creating a Two-Page
• Resume: Prioritize most relevant and recent experience
• Use concise, results focused language
• Align language from the job announcement
• Focus on demonstrating skills and competencies
• Remove outdated or unrelated experience Use the
• USAJOBS resume builder
• Additional guidance on this new requirement and resume building tools can be found at: https://help.usajobs.gov/faq/application/documents/resume/page-limit. https://www.opm.gov/policy-data-oversight/hiring-information/merit-hiring-plan-resources/applicant-guidance-on-the-two-page-resume-limit/ This position is a hybrid title 38 occupation reported among the occupations with the largest staffing shortages and, therefore, under 38 U.S.C. § 7412 waives the requirement to apply
• Veterans' preference to applicants for Fiscal
• Year 2026. Current, Permanent Federal
• Employees are asked to upload a copy of the most recent
• SF-50 (that is not for an award), indicating current
• Federal employment. This job opportunity announcement may be used to fill additional vacancies. Veterans' preference does not apply.