Medical Records Technician (Coder - Inpatient) Job in Anywhere in the U.S. (remote job)

Vacancy No. CBSR-12810527-26-LM Department Veterans Health Administration
Salary $55,328.00 to $71,932.00 Grade 8 to 8
Perm/Temp Permanent FT/PT Full-time
Open Date 10/3/2025 Close Date 10/10/2025
Job Link Apply Online Who may apply Public
Locations:
Anywhere in the U.S. (remote job)


Summary

The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder-Inpatient) position. The Medical Records Technician (Coder -Inpatient) is located in the Health Information Management Services (HIMs) section within Patient Care Administrative Service.




This job is open to

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below. This announcement is open to United States Citizens ***If you ARE A CURRENT federal employee please apply to vacancy CBSR-12810525-26-LM***

Duties

Major duties of the Medical Records Technician (Coder - Inpatient) include, but are not limited to:

  • Reviewing record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder).
  • use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled.
  • Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. Has basic knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
  • Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems 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 (E/M) code to ensure ethical, accurate, and complete coding.
  • Maintains current knowledge of regulatory and policy requirements affecting coded information.
  • Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data.
  • Insures provider documentation supports the diagnoses and procedures coded.
  • Consults with a more senior coder or the supervisor to resolve issues related to conflicting or questionable clinical documentation.
  • Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment.
  • Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
  • Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
  • Researches references to resolve any questionable code errors; contacts a senior coder or supervisor when needed.
  • Code recurring MDS census for NHCU patients and other special surveys before closeout with knowledge of Prospective Payments Systems such as Resident Assessment Instrument/Minimum Data Set (RAI/MDS), Home Health CMS requirements and Fee Basis Coding.
  • 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.
  • Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
  • Codes inpatient professional fee services for identified inpatient admissions.
  • Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement.
  • Codes less complex Operating Room procedures reported in the Surgical Package of the Vista hospital system.
  • Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions
Work Schedule: Monday- Friday, 8:00am - 4:30pm
Remote: 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. Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order.
Virtual: This is not a virtual position.
Functional Statement #: 91791A
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.
  • 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 evaluation.
  • 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.
  • English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
  • Education or Experience:
  • (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); (Transcript Required) 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,
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:
  • 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
  • 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 possess one of the following certifications:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
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: MRT (Coder- Inpatient) One year of creditable experience equivalent to the next lower grade level (GS-7). Examples of creditable experience includes: Selecting and assigning codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. Review and record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder). 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. Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature. Query clinical staff with documentation requirements to support the coding process. Use various computer applications to abstract records, assign codes, and record and transmit data. Ensure audit findings have been corrected and refiled.

AND
  • Experience. One year of creditable experience equivalent to the next lower grade level.
  • Demonstrated KSAs:
  • Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient 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 inpatient 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 inadequate guidelines.

Preferred Experience: Experience in DRG inpatient coding. Professional Service coding (CPT) and Inpatient PCS procedure coding.

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: The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, small parts; or driving an automobile, etc. No special physical demands are required to perform the work. The work environment involves everyday risks or discomforts which require normal safety precautions typical of such places as offices, meeting and training rooms, or libraries. The work area is adequately lighted, heated, and ventilated.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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

"VA Healthcare System Serving Ohio, Indiana and Michigan (VISN 10) advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being."

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.

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.

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; 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 (when listing previous employment please include month and year).
  • Certification. (Unexpired Certification)
  • If prior military service, include all copies of your DD-214 or proof of service as well as proof of disability, if applicable. You must submit your documentation showing character of discharge.
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
  • DD-214/ Statement of Service
  • Disability Letter (Schedule A)
  • Disability Letter (VA)
  • License
  • CV
  • Other (2)
  • Other (3)
  • Performance Appraisal
  • Professional Certification
  • Resume
  • Separation Notice (RIF)
  • 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.

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 10/10/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12810527.

  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.

Areas of Consideration - Preference veterans will receive first consideration and will be referred in the following order:
  • CPS/CP: A veteran who served at any time and who has a compensable service-connected disability rating of at least 10 percent.
  • XP: A veteran who served at any time and has a present service-connected disability or is receiving compensation, disability retirement benefits, or pension from the military or the Department of Veterans Affairs but does not qualify as a CP or CPS; or is a purple heart recipient.
  • TP: 5-point preference based on eligible active duty service.
  • SSP (Sole Survivorship Preference): Discharged from active duty from the armed forces, after August 29, 2008, by reason of a "sole survivorship discharge."
  • All other qualified US citizens.

Agency contact information

Ronda Thorpe
Address
VA Northeast Ohio Healthcare System
10701 East Boulevard
Cleveland, OH 44106
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.


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