Lead MRT (Coder)

DaMar Staffing; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

James J Peters VA Medical Center is seeking a qualified MRT (Coder) to classify medical data from patient health records in inpatient and outpatient settings. The role requires strong medical terminology, anatomy, physiology, and coding knowledge to assign codes accurately and maintain data integrity.

Responsibilities include selecting appropriate ICD, CPT, and HCPCS codes, reviewing records for completeness, and ensuring compliance with regulatory requirements.

Qualifications

• One year of creditable experience in medical terminology, anatomy, physiology, and health records.
• Associate degree with 12 credit hours in health information technology/health information management.
• AHIMA or AAPC certification program completion.
• Knowledge of ICD, CPT, and HCPCS coding systems.

Responsibilities

• Assigns codes to inpatient and outpatient encounters.
• Applies knowledge of medical terminology, anatomy, physiology, diseases, procedures, and coding practices.
• Selects and assigns codes from ICD, CPT, HCPCS.
• Reviews health records to ensure complete data capture and quality.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health information management

Education

Associate degree in Health Information Technology/Health Information Management

AHIMA/AAPC certification program

Tools

ICD-10-CM coding systems

CPT coding

HCPCS coding

Job description

Summary

This position is in the Health Information Management (HIM) section at the James J Peters 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.

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Duties

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• Assigns codes to documented patient care encounters (Inpatient and/or outpatient).
• Applies advance knowledge of medical terminology, anatomy, and physiology, disease processes, treatment modalities, diagnostics tests, medications, procedures as wells as the principles and practices of health services.
• Selects and assign codes from several coding systems
• Monitors ever changing regulatory requirements affecting coding information
• Performs comprehensive review of the patient health records to abstract medical surgical, ancillary, demographic, social and administrative data to ensure complete data capture.
• Monitors the status and progress of work and day to day adjustments
• Instruct employees in specific tasks and job techniques
• Provides job training to new coders
• Review and make improvements in documentation systems used to provide patient care

Work Schedule

Mon - Fri 08:00a - 1630 EST

Compressed/Flexible: n/a

Virtual: This is not a virtual position.

Functional Statement #: 136010

Requirements

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Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• 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 dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical / assessment 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 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;
• 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 0675 MRT (Coder) all grade levels

• 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 :
  • (1) 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.
  • (2) 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,

• (3) Completion of 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,

• (4) 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:
  • (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.

• (1) Apprenticeship/Associate Level Certification through AHIMA or AAPC.
• (2) Mastery Level Certification through AHIMA or AAPC.
• (3) 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.

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: (1) Such employees may be reassigned, promoted up to and including 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. (2) 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. (3) 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. (4) 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. (5) 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. 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

Lead Medical Records Technician (Coder), GS-9 candidates must meet the basic requirements above and all of the grade determinations below:

• Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder), GS-8. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. The experience is described as: select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Certification. Employees at this level must have a mastery level certification Mastery Level Certification through AHIMA or AAPC.
• Demonstrated Knowledge, Skills, and Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of the following KSAs.
  • (1) Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc.
  • (2) Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  • (3) Ability to effectively communicate, both orally and in writing, in order to meet program objectives.
  • (4) Knowledge of training methods and the ability to provide training to new coding staff.
  • (5) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
  • (6) Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is GS-9.

Physical Requirements:

See VA Directive and Handbook 5019. Work requires prolonged hours of sitting and computer use.

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

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.

Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.

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