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Lead Medical Records Technician (Coder)

Department of Veterans Affairs
Veterans Health Administration
TIBOR RUBIN VA MEDICAL CENTER, Long Beach CA - Health Administration Service
This job announcement has closed

Summary

This position is located in the Health Information Management section at the VA Long Beach Healthcare System. The Lead Medical Records Technician Coder works within a team environment, supporting peers in meeting goals, deadlines handling multiple tasks with frequently changing projects and deadlines. Is skilled in classifying medical data from patient health records in the hospital setting and physician based settings.

Welcome to VA Long Beach

Tibor Rubin - History

Overview

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Reviewing applications
Open & closing dates
05/13/2025 to 05/20/2025
Salary
$71,244 to - $92,615 per year
Pay scale & grade
GS 9
Location
1 vacancy in the following location:
Long Beach, CA
1 vacancy
Remote job
No
Telework eligible
Yes—as determined by the agency policy.
Travel Required
Not required
Relocation expenses reimbursed
No
Appointment type
Permanent
Work schedule
Full-time
Service
Excepted
Promotion potential
None
Supervisory status
No
Security clearance
Other
Drug test
No
Position sensitivity and risk
Non-sensitive (NS)/Low Risk
Trust determination process
Financial disclosure
No
Bargaining unit status
No
Announcement number
CBSX-12735093-25-MA
Control number
836812700

This job is open to

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Clarification from the agency

Current Long Beach VA Medical Center employees will be given 1st consideration. SF-50s must be submitted as proof of current employment. If you do not submit SF-50, you will not be given 1st consideration.

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Duties

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  • Assigns codes to documented patient care encounters (Inpatient and/or outpatient).
  • Applies advance knowledge of medical terminology, anatomy, and physiology, disease processes, treatment modalities, diagnostics tests, medications, procedures as wells as the principles and practices of health services.
  • Selects and assign codes from several coding systems
  • Monitors ever changing regulatory requirements affecting coding information
  • Performs comprehensive review of the patient health records to abstract medical surgical, ancillary, demographic, social and administrative data to ensure complete data capture.
  • Monitors the status and progress of work and day to da adjustments
  • Instruct employees in specific tasks and job techniques
  • Provides job training to new coders
  • Review and make improvements in documentation systems used to provide patient care
Work Schedule: Monday - Friday 7:30am=4:00p,
Telework: AdHoc
Virtual: This is not a virtual position.
Functional Statement #: 00000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
PCS Appraised Value Offer (AVO): Not Authorized

Requirements

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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).

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:

  • Citizenship: Citizen of the United States.
  • English/Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).
  • 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.
  • 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:
      • 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).
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 GS-09:Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder).

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. Lead MRTs (Coder) must be able to perform all duties of a MRT (Coder). Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate, prepare, and maintain various reports, and analyze data; and may also coordinate, assign, and monitor workflow. They provide input for performance evaluations and hiring. They orient and instruct new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software. They ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection. They monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs. They develop coding training materials and present a curriculum encompassing ongoing training initiatives. They provide assistance with coding inquiries from providers, MRTs (Coder), billers, and other facility staff. Lead MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Lead MRTs (Coder) may be at a facility or in a consolidated coding unit (CCU).

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  1. Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc.
  2. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  3. Ability to effectively communicate, both orally and in writing, in order to meet program objectives.
  4. Knowledge of training methods and the ability to provide training to new coding staff.
  5. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
  6. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: The work is sedentary and is usually accomplished while the incumbent is comfortably seated at a desk or table. Some walking and standing may occur in the course of a workday in connection with attendance at meetings and conferences, or while researching assignments. Items carried typically are light objects such as, briefcases, notebooks, and reports. Lifting of moderately heavy objects is not normally required.

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

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.

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.

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