Medical Records Technician (Coder-Outpatient and Inpatient)

Veterans Health Administration; Hines (IL); Sur place; USD 70 000 - 90 000; Plein temps

Résumé du poste

The Veterans Health Administration is seeking a skilled Medical Records Technician - Coder (GS-0675) to analyze health records and assign accurate diagnoses and procedure codes for outpatient and inpatient services. The role requires strong knowledge of medical terminology, coding guidelines, and documentation quality.

Candidates must meet basic requirements, possess an associate degree or approved coding training, and hold relevant AHIMA or AAPC certifications.

Qualifications

• Must demonstrate ability to analyze health records to identify diagnoses and procedures.
• Ability to perform full outpatient and inpatient coding for professional services.
• Understanding of health information guidelines and documentation quality.

Responsabilités

• Analyze health records to identify diagnoses and procedures for coding accuracy.
• Perform outpatient and inpatient coding for professional services, ensuring billable accuracy.

Connaissances

Health record analysis

Outpatient coding

Inpatient coding

Medical terminology

Formation

Associate degree in health information technology/health information management

12 semester hours in health information technology/health information management

Outils

AHIMA/AAPC certifications training

Description du poste

This Announcement will close on Friday, October 16, 2026 -OR- once it reaches 30 applicants. To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 10/16/2026.

Basic Requirements

Citizenship: Citizen of the United States. Experience and Education: Must have one of the following:

• 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.
• 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;
• 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 for meeting the basic requirements.

Certification

Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:

• (1) Apprentice/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.

GS-8 Grade Requirements

Experience: Must have one year of creditable experience equivalent to the next lower grade level.

Demonstrated Knowledge, Skills, and Abilities:

• 1) 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 findings, and the disease process/pathophysiology of the patient.
• 2) Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
• 3) 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.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. 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-8. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.