Medical Records Technician (Coder-Outpatient and Inpatient)

U.S. Department of Veterans Affairs; Hines (IL); Remote; USD 60,000 - 90,000; Full time

Job summary

The U.S. Department of Veterans Affairs Hospital in Illinois seeks a Medical Records Technician (MRT) coder to classify patient data from health records for inpatient and outpatient services. You will code using ICD, CPT, and HCPCS and ensure accurate documentation supports proper reimbursement.

The role requires knowledge of health information terminology, coding guidelines, and the ability to handle complex record reviews. Telework: available; work schedule aligns with hospital operations.

Qualifications

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding.
• Ability to perform full outpatient coding including ambulatory surgical cases and outpatient encounters.
• Skill in interpreting and adapting health information guidelines with incomplete or gaps.

Responsibilities

• Assigns codes to documented patient encounters (inpatient and outpatient).
• Selects codes from ICD, CPT, HCPCS using current coding guidelines.
• Reviews health records to ensure complete data capture and proper coding.

Skills

Health record analysis

Outpatient coding

Guidelines interpretation

Education

AA degree in health information technology/health information management

AHIMA/AAPC certification eligibility

Tools

VistA/CPRS

Encoder product suite

Outlook/Excel/Word/Access

Job description

Summary

This Announcement will close on Friday - October 16 - 2026 -OR- once it reaches 30 applicants.

Qualifications

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
• 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
• 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
• 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
• AND - 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.

Duties

• This position is located in the Health Information Management (HIM) section at the Edward Hines Jr
• VA Hospital
• MRTs (Outpatient/Inpatient 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 and responsibilities of this position include - but are not limited to the following: Basic Functions: Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the Edward Hines - VAMC
• 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
• 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
• Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record
• Utilizes the facility computer system and software applications to correctly code - abstract - record - and transmit data to the national VA database
• 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
• Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs - at the direction of the supervisor - on unit operations - coding - abstracting - and use of an electronic health record
• Specific Functions: Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge
• also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG)
• Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed
• corrects coding as needed to ensure proper patient classification in the VERA program
• Codes inpatient professional fee services for identified inpatient admissions
• Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations - instructions - and requirements for allowable reimbursement
• links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system
• applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite
• ensures all procedures file to the appropriate Patient Care Encounter (PCE)
• adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases
• Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay admissions to reflect all patient conditions and care up to the census date or to the requested billing date
• Reviews and codes assigned fee service Care in the Community patient encounters (inpatient and outpatient) using the paper or electronic documentation obtained from non-VA facilities
• Codes diagnoses from paper forms for VA registries
• Work Schedule: Monday-Friday - 8:00am -4:30pm Telework: Available Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required