Medical Records Technician (Coder-Outpatient and Inpatient) Job in Perry Point, MD

Vacancy No. CBTF-12772860-25-PB Department Veterans Health Administration
Salary $39,722.00 to $79,263.00 Grade 4 to 8
Perm/Temp Permanent FT/PT Full-time
Open Date 8/27/2025 Close Date 9/4/2025
Job Link Apply Online Who may apply Status Candidates
Locations:
Perry Point, MD


Summary

This position is in the Health Information Management (HIM) section at the (VAMHCS). Medical Records Technician (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 alpha-numeric codes for each diagnosis and procedure.

Duties

Major Duties may Include:

  • Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services.
  • Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding.
  • With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
  • Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
  • Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed.
  • Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the health record applications (Vista and CPRS) as well as the encoder product suite.
  • 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. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Maintains current knowledge of regulatory and policy requirements affecting coded information.
  • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
  • Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
  • 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.
  • Identifies the principal diagnosis and principal procedure 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). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and procedure codes are selected from the current version of the ICD coding system.
  • Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
  • Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
  • Outpatient coding: Must be able to code and close outpatient encounters at the sustained rate of seventy (70) encounters per workday.
  • Inpatient coding: Must be able to code and close inpatient treatment files with PRO fees at the sustained rate of 9 records per workday. Must be able to code and close inpatient treatment files without PRO fees at the sustained rate of 13 records per workday

Work Schedule: Monday - Friday 7:30am - 4pm
Telework: Available
Virtual: This is not a virtual position.
Functional Statement #:512-25588-F; 512-25589-F; 512-25154-F; 512-25155-F; 512-25151-F
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 trial 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.
  • 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).

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. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
  • Experience and Education: 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 (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); 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. 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
Grade Determinations:
MRT (Coder-Outpatient and Inpatient) GS-4
  • Experience or Education. None beyond basic requirements.
MRT (Coder-Outpatient and Inpatient) GS-5
  • Experience. One year of creditable experience equivalent to the next lower grade level; OR,
  • Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
In addition to the experience above, candidate must demonstrate all KSAs
  1. Ability to use health information technology and various office software products used in MRT (Coder) positions (e.g., the electronic health record, coding and abstracting software, etc.).
  2. Ability to navigate through and abstract pertinent information from health records.
  3. Knowledge of the ICD CM, PCS Official Conventions and Guidelines for Coding and Reporting, and CPT guidelines
  4. Ability to apply knowledge of medical terminology, human anatomy/physiology, and disease processes to accurately assign codes to inpatient and outpatient episodes of care based on health record documentation.
  5. Acknowledge of The Joint Commission requirements, CMS, and/or health record documentation guidelines.
  6. Ability to manage priorities and coordinate work to complete duties within required timeframes, and the ability to follow-up on pending issues.
MRT (Coder-Outpatient and Inpatient) GS-6
  • Experience. One year of creditable experience equivalent to the next lower grade level.
In addition to the experience above, candidate must demonstrate all KSAs
  1. Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
  2. Ability to determine whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support the assigned codes. This includes the ability to take appropriate actions if health record contents are not complete, accurate, timely, and/or reliable.
  3. Ability to apply laws and regulations on the confidentiality of health information (e.g. Privacy Act, Freedom of Information Act, and HIPAA).
  4. Ability to accurately apply the ICD CM PCS Official Conventions and Guidelines for Coding and Reporting, and CPT Guidelines to various coding scenarios
  5. Comprehensive knowledge of current classification systems, such as ICD CM PCS, CPT, HCPCS, and skill in applying classifications to both inpatient and outpatient records based on health record documentation.
  6. Knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG.
MRT (Coder-Outpatient and Inpatient) GS-7
  • Experience. One year of creditable experience equivalent to the next lower grade level.
In addition to the experience above, candidate must demonstrate all KSAs
  1. Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas to accurately reflect service and care provided based on documentation in the health record
  2. Ability to communicate with clinical staff for specific coding and documentation issues, such as recording inpatient and outpatient diagnoses and procedures, the correct sequencing of diagnoses and/or procedures, and the relationship between health record documentation and code assignment
  3. Ability to research and solve coding and documentation related issues
  4. Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
  5. Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC) and POA indicators to obtain correct MS-DRG
MRT (Coder-Outpatient and Inpatient) GS-8
  • Experience. One year of creditable experience equivalent to the next lower grade level.
In addition to the experience above, candidate must demonstrate all KSAs
  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 comments 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 inpatient facility coding, including inpatient discharges surgical cases diagnostic studies and procedures and inpatient professional services.
  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.

Education

  • Foreign Education. To be creditable, education completed outside the the U.S. must be deemed at least equivalent to that gained in conventional U.S. program by a private organization specializing in the interpretation of foreign educational credentials. Graduates of foreign baccalaureate degree programs meet the educational requirements if they meet either of the following:
  1. Foreign transcripts are evaluated by an acceptable evaluation agency, and the degree is found to be equivalent to a NAACLS-approved U.S. clinical laboratory science degree program. OR,
  2. The applicant submits a letter from ASCP BOC or AMT stating the individual is eligible to take the certification examination.
Preferred Experience: Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the
principles and practices of health services and the organizational structure to ensure proper code selection. 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).

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-4. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.

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

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

Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:

  1. Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
  2. Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
  3. MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
  4. MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
  5. Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.
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.

You will be evaluated for this job based on how well you meet the qualifications above.

Area of Consideration - Eligible applications will be reviewed and referred in the following order:
1. Current permanent VA employees of the facility.
2. All other VA employees.
3. Current permanent Federal employees of other agencies.


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
  • SF-50/ Notification of Personnel Action


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
  • Other (1)
  • Professional Certification
  • Resume
  • 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 09/04/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12772860.

  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

Prudence Barrett
Address
VA Maryland Health Care System
10 North Greene Street
Baltimore, MD 21201
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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