Duties
PLEASE NOTE: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S. Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements. Any selected candidate must live within 50 miles of a VA Medical Center.
Duties include, but are not limited to:
- Medical Records Technician - Coder Auditors must be able to perform all duties of a MRT (Coder).
- Through prospective and retrospective audits, they identify coding errors and documentation gaps, consult with clinical staff, provide education and recommendations, and support regulatory compliance by monitoring data quality and reporting audit findings.
- Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding.
- Auditors perform audits of encounters to identify areas of non-compliance in coding.
- Responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, the appropriate workload is captured, and resources are properly allocated.
- Review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
- Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients.
- Develop and/or update medical center policies pertaining to clinical documentation improvement.
- Serve as technical experts in health record content and documentation requirements.
- Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
- Review the appropriateness of and responses to queries through a review of query reports.
- Review health record documentation, develop criteria, collect data, graph and analyze results, create reports, communicate orally and/or in writing to appropriate groups and leadership.
- Obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices when applicable.
- Adhere to established documentation requirements outlined by the accrediting agency's guidelines, regulations, policies, and medical-legal requirements.
- Monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education.
- Responsible for developing and implementing active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to meet the CDIS program objectives.
- Provide training in small or large groups, educating clinical staff about current documentation standards and improving techniques, including accurate and ethical documentation practices.
- Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and accurately reflect medical necessity and level of service or procedure performed in the outpatient setting.
Work Schedule: Full-time, Monday-Friday; Tour of duty will be set between 8:00am - 4:30pm EST.
Compressed/Flexible:
NOT Available
Telework: Yes-This position is telework eligible and exempted from return to office requirements. This position will be reviewed annually and do not imply permanent telework status. Current employees will be granted an exception to remain in the current duty station location if outside VISN 8.
Functional Statement #: PD82038F
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
Physical Requirements: The work is sedentary. Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work. Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site. Incumbent may carry and lift light items weighing less than 15 pounds.
**ALL APPLICANTS MUST POSSESS A CURRENT MRT CERTIFICATION THROUGH AHIMA OR AAPC. A COPY MUST BE SUBMITTED WITH YOUR APPLICATION.
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.
- 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 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 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:
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 OR
- (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 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
- (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. 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.
English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
***ALL APPLICANTS MUST POSSESS A CURRENT MRT CERTIFICATION THROUGH AHIMA OR AAPC AND A COPY MUST BE SUBMITTED WITH YOUR APPLICATION.
Grade Determinations:
Medical Records Technician (Coder) Auditor, GS-9
Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder). Specialized experience includes: 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 in adequate guidelines.
Certification. Employees at this level must have a mastery level certification.
Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
1. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).
2. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.
4. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
5. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.
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.
Education
Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).
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.
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Note: If your school has changed names, or is no longer in existence, you must provide this information in your application.
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.
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.
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.
Required Documents
To apply for this position, you must provide a complete Application Package which includes:
- Resume
- SF-50/ Notification of Personnel Action
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 Document. 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
- Resume
- Professional Certification
- Resume
- SF-15
- SF-50/ Notification of Personnel Action
- Transcript
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit
Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
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.