Medical Records Technician - Coder Inpatient Job in Salt Lake City, UT

Vacancy No. CBSU-12705932-25-MC Department Veterans Health Administration
Salary $36,049.00 to $71,932.00 Grade 4 to 8
Perm/Temp Permanent FT/PT Full-time
Open Date 3/10/2025 Close Date 3/21/2025
Job Link Apply Online Who may apply Public
Locations:
Salt Lake City, UT


Summary

This position is located in the Health Information Management (HIM) section at the Salt Lake City 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. These coding practitioners analyze and abstract patients' health records, and assign alpha­numeric codes for each diagnosis and procedure.

This job is open to

Clarification from the agency

All US Citizens ***If you ARE a current, permanent federal employee, please apply to the internal announcement CBSU-12705933-25-MC***

Duties

  • Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the 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 E/M code to ensure ethical, accurate, and complete coding.
  • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
  • 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.
  • 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 in Austin.
  • 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.
  • Works within a team environment; supports peers in meeting goals and deadlines.

Work Schedule: 8AM to 4:30PM Monday-Friday
Telework: May be available on an ad-hoc basis as determined by the agency policy
Virtual: This is not a virtual position
Functional Statement #: 58275-O, 58276-O, 58277-O, 58278-O, 58279-O
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

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 probationary 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).
  • Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

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

English Language Proficiency: MRT Coders must be proficient in spoken & written English as required by 38 U.S.C. § 7403(f)

Experience and/or Education: Must have 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, & the structure & format of health records
OR
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/management (e.g., courses in medical terminology, anatomy/physiology, medical coding, & introduction to health records)
OR
Completed an AHIMA approved coding program, or other intense coding training program of approximately 1 year or more that included courses in anatomy & physiology, medical terminology, basic ICD diagnostic/procedural, & basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, & 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
Have a combination of experience/education. The following educational/training substitutions are appropriate for combining education & creditable experience:
  • Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding & the health record, & 1 year above high school with a minimum of 6 semester hours of health information technology courses
  • 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 & 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, & health record techniques & 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 VHA must have either:
  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

Grade Determinations:
GS4
Experience or Education: None beyond basic requirements

GS5
Experience or Education:Must have 1 year of creditable experience equivalent to the next lower grade level of GS4
OR
Successful completion of a bachelor's degree from an accredited college/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

Demonstrated Knowledge, Skills, & Abilities (KSAs): In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • Ability to use health information technology & various office software products used in MRT Coder positions (e.g., the electronic health record, coding & abstracting software, etc.)
  • Ability to navigate through & abstract pertinent information from health records
  • Knowledge of the ICD CM & PCS Official Conventions & Guidelines for Coding & Reporting
  • Ability to apply knowledge of medical terminology, human anatomy/physiology, & disease processes to accurately assign codes to inpatient records based on health record documentation
  • Knowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines
  • Ability to manage priorities & coordinate work to complete duties within required timeframes & the ability to follow-up on pending issues

GS6
Experience: 1 year of creditable experience equivalent to the next lower grade level of GS5

Demonstrated Knowledge, Skills, & Abilities (KSAs): 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 & procedures for coding & 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, & 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 & regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, & HIPAA)
  • Ability to accurately apply the ICD CM & PCS Official Conventions & Guidelines for Coding & Reporting to various coding scenarios
  • Comprehensive knowledge of current classification systems, such as ICD Clinical Modification (CM) & PCS, CPT, & HCPCS, & skill in applying said classifications to inpatient records based on health record documentation
  • Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators to obtain correct Medicare Severity Diagnosis Related Group (MS-DRG)
GS7
Experience: 1 year of creditable experience equivalent to the next lower grade level of GS6

Demonstrated Knowledge, Skills, & Abilities (KSAs): 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 specialty care areas to accurately reflect service & care provided based on documentation in the health record
  • Ability to communicate with clinical staff for specific coding & documentation issues, such as recording diagnoses & procedures, the correct sequencing of diagnoses and/or procedures, & the relationship between health record documentation & code assignment
  • Ability to research & solve coding & documentation related issues
  • Skill in reviewing & correcting system or processing errors & ensuring all assigned work is complete
  • Ability to abstract, assign, & sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), & POA indicators, to obtain correct MS-DRG
GS8
Experience: 1 year of creditable experience equivalent to the next lower grade level of GS7

Demonstrated Knowledge, Skills, & Abilities (KSAs): 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 & procedures for inpatient coding & to evaluate the adequacy of the documentation. This includes the ability to read & understand the content of the health record, the terminology, the significance of the comments, & the disease process/pathophysiology of the patient
  • Ability to accurately perform the full scope of inpatient coding, including inpatient discharges, surgical cases, diagnostic studies & procedures, & inpatient professional services
  • Skill in interpreting & adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, & 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/.

The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS4 to GS8.

Physical Requirements: See VA Directive & Handbook 5019, Employee Occupational Health Service.

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

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.

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.

Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.

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.

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.

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:

  • Professional Certification
  • Resume



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)
  • License
  • Other (1)
  • Other (2)
  • Professional Certification
  • Proof of Marriage Status
  • 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.

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 03/21/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12705932.

  1. 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.
  2. 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.

Agency contact information

VISN 19 HR Contact Center
Address
VA Salt Lake City Health Care System
500 Foothill Drive
Salt Lake City, UT 84148
US

Next 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.


Note: We cannot accept applications on behalf of Federal Agencies. Application instructions are listed within the Job Description.


© 2006-2025, exclusive of U. S. government job opportunity announcements