Duties
Medical Record Technicians (MRT) 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. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Some duties may include but are not limited too:
- Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
- Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- Ensures provider documentation is complete and supports the diagnoses and procedures coded.
- Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database
Work Schedule: Monday-Friday, 7:00am to 3:30pm
Telework: Ad-hoc
Virtual: This is not a virtual position.
Functional Statement #: F06082, F06083, F06084, F06085, F06086
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
- Veterans' preference does not apply for internal or other current permanent Federal agency employees.
- Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held.
- This position is a NAGE Bargaining Unit position.
- This position is covered by locality-based comparability pay.
- Narrative responses to the knowledge, skills and abilities (KSAs) may be required from the selectee in order to proceed with the appointment.
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.
- You may be required to serve a trial period.
- 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 dentification 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).
Qualifications
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.
- Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.
- English Language Proficiency: MRTs (ROI) 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
- Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements. The following experience and educational/training substitutions are appropriate for combining education and creditable experience:
- (a) 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.
- (b) 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: 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.
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).
Preferred Experience: Ideally an experienced Outpatient and Inpatient Coder who is certified via AHIMA or AAPC. VA experience is preferred but not required. Teamwork skills, tech savvy, good communicator.
Grade Determinations: Medical Records Technician (Coder-Outpatient and Inpatient)
GS-4:
- Experience or Education. None beyond basic requirements.
- Experience. One year of creditable experience equivalent to the next lower grade level;
- Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
- In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
- Ability to navigate through and abstract pertinent information from health records.
- Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines.
- Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
- Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
- Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.
- Experience. One year of creditable experience equivalent to the next lower grade level.
- In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
- Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
- Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and HIPAA).
- Ability to accurately apply the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios.
- Comprehensive knowledge of current classification systems, such as ICD CM, PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
- Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Education
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: 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/.
Additional information
GS-7
- Experience. One year of creditable experience equivalent to the next lower grade level.
- In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record.
- Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment.
- Ability to research and solve coding and documentation related issues.
- Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete.
- Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators to obtain correct MS-DRG.
- Experience. One year of creditable experience equivalent to the next lower grade level.
- In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Ability to analyze the health 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 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 outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility 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.
Receiving Service Credit or 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.
Benefits
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
Area of Consideration - Eligible applications will be reviewed and referred in the following order:
1. Current permanent VA employees of the facility.
2. All other VA employees.
3. Current permanent Federal employees of other agencies.
4. All other applicants.
Note: Veterans' Preference is not applicable to VA employees or employees of other Federal agencies.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
Benefits
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
Required Documents
As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have - whether you're a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you're eligible under their policies.
To apply for this position, you must provide a complete Application Package which includes:
- Resume
Resume Reminder:
Your resume must include the following information each job listed:- Job title
- Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2007 to April 2008)
- Full-time or part-time status (include hours worked per week)
- Series and Grade, if applicable, for all Federal positions you have held
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
An incomplete application will receive a rating of IFFM (ineligible due to missing forms). Requests for reconsideration will not be considered for applicants who fail to submit a complete application package.
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)
- Professional Certification
- Resume
- Separation Notice (RIF)
- SF-15
- SF-50/ Notification of Personnel Action
- Transcript
If you are a current federal employee, you must attach your most recent, non-award SF-50. This SF-50 should not be more than a year old and must show your current position, grade, and step. Award SF-50's typically do not provide sufficient information and will not be accepted if they do not include Grade and Step.
In order to clearly demonstrate you possess the time-in-grade as required by the announcement, additional SF-50s should be attached which clearly demonstrate the minimum time-in-grade requirement.
Examples of appropriate SF-50's include:- Within grade increases at the highest grade held
- Promotions with an effective date more than one year old
- SF-50's at the highest grade held with an effective date more than one year old
Veterans' preference does not apply for internal or other current permanent Federal agency employees.If you are relying on your education to meet qualification requirements:
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. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
How to Apply
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 07/31/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12759297.
- To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
- Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
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.Agency contact information
Mary DignardAddressVA Bedford Healthcare System
200 Springs Road
Bedford, MA 01730
USNext steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.Fair and Transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
- Criminal history inquiries
- Equal Employment Opportunity (EEO) Policy
- Financial suitability
- New employee probationary period
- Privacy Act
- Reasonable accommodation policy
- Selective Service
- Signature and false statements
- Social security number request
Required Documents
To apply for this position, you must provide a complete Application Package which includes:
- Resume
Resume Reminder:
Your resume must include the following information each job listed:
- Job title
- Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2007 to April 2008)
- Full-time or part-time status (include hours worked per week)
- Series and Grade, if applicable, for all Federal positions you have held
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
An incomplete application will receive a rating of IFFM (ineligible due to missing forms). Requests for reconsideration will not be considered for applicants who fail to submit a complete application package.
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)
- Professional Certification
- Resume
- Separation Notice (RIF)
- SF-15
- SF-50/ Notification of Personnel Action
- Transcript
If you are a current federal employee, you must attach your most recent, non-award SF-50. This SF-50 should not be more than a year old and must show your current position, grade, and step. Award SF-50's typically do not provide sufficient information and will not be accepted if they do not include Grade and Step.
In order to clearly demonstrate you possess the time-in-grade as required by the announcement, additional SF-50s should be attached which clearly demonstrate the minimum time-in-grade requirement.
Examples of appropriate SF-50's include:
- Within grade increases at the highest grade held
- Promotions with an effective date more than one year old
- SF-50's at the highest grade held with an effective date more than one year old
Veterans' preference does not apply for internal or other current permanent Federal agency employees.
If you are relying on your education to meet qualification requirements:
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. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
This job is open to
- The public
U.S. Citizens, Nationals or those who owe allegiance to the U.S.
- Federal employees - Competitive service
Current federal employees whose agencies follow the U.S. Office of Personnel Management's hiring rules and pay scales.
- Federal employees - Excepted service
Current federal employees whose agencies have their own hiring rules, pay scales and evaluation criteria.
- Internal to an agency
Current federal employees of the hiring agency that posted the job announcement.
Clarification from the agency
Open to current permanent Department of Veterans Affairs employees, current permanent Federal employees of other agencies and all US Citizens.
