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Lead Medical Records Technician (Coder)

Department of Veterans Affairs
Veterans Health Administration
Lt. Col. Luke Weathers, JR. VA Medical Center

Summary

This position is in the Health Information Management (HIM) section at the Lt. Col. Luke Weathers, Jr. VA Medical Center. Medical Records Technicians (MRT) (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.

Overview

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Accepting applications
This job will close when we have received 50 applications which may be sooner than the closing date. Learn more
Location
1 vacancy in the following location:
Work site options
Telework eligible
Not applicable, this is a remote position.
Remote job
Yes - This position currently has a mid-term Return to Office (RTO) extension of 180 days. Please note that this extension is subject to change. Candidates may be required to return to the office if agency policy is updated or if the exemption is not extended.
Relocation expenses reimbursed
No
Salary
$61,722 - $80,243 per year
Pay scale & grade
GS 9
Promotion potential
None
Pay scale and grade determines the salary of the job.
Work schedule
Full-time
Travel Required
Not required
Appointment type
Permanent
Occupations and job series
Supervisory status
No
Federal service type
This job is in the Excepted Service
Represented by a union
No
Drug test
No
Security clearance
Other
Position sensitivity and risk
Non-sensitive (NS)/Low Risk
Jobs require a background check and some require a security clearance. The type depends on the job.
Background check type
Financial disclosure required
No
Some jobs require financial disclosure to identify conflicts of interests.
Announcement number
CBTG-13093587-27-HS
Control number
889124800

This job is open to

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Clarification from the agency

All qualified candidates encouraged to apply. Open to U.S. Citizens. Area of Consideration- Eligible applications will be reviewed and referred in the following order: 1. Current permanent Federal employees of other agencies. 2. All other applicants based on Veterans' Preference. NOTE: The 2-page Resume requirement does not apply to this position.

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Duties

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These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. 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.

Duties include but are not limited to the following:

  • Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.
  • Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), 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.
  • 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 electronic 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; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
  • 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.
  • 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.
  • Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill, and ability to perform the full range of routine and non-routine responsibilities required.
  • Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture.
  • Reviews, audits, trains, monitors, and completes special assignments within specified time frames.


Work Schedule: Monday - Friday; 7:30 am - 4:00 pm
Telework: Not Available.
Remote: This position currently has a mid-term Return to Office (RTO) extension of 180 days. Please note that this extension is subject to change. Candidates may be required to return to the office if agency policy is updated or if the exemption is not extended. Must be able to travel within 50 miles of a VA Facility if remote status is cancelled.
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized.
Permanent Change of Station (PCS): Not Authorized.

Requirements

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Conditions of employment

  • You must be a U.S. Citizen to apply for this job.
  • To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the 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 identification 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:

  • English Language Proficiency - MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ยง 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.
NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. 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-9 Lead Medical Records Technician (Coder)
  • 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.
  • Demonstrated Knowledge, Skills, and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs:
    • 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.
    • 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.
    • Ability to effectively communicate, both orally and in writing, in order to meet program objectives.
    • Knowledge of training methods and the ability to provide training to new coding staff.
    • Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
    • 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/.

This vacancy is above the full performance level at the GS-9.

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

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

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.

Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application. Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement. To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments.

Receiving Service Credit for 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.

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.

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.

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following Competencies for this position:

  • Attention to Detail
  • Customer Service
  • Decision Making
  • Flexibility
  • Integrity/Honesty
  • Interpersonal Skills
  • Learning
  • Reading Comprehension
  • Self-Management
  • Stress Tolerance
  • Teamwork


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.

Veterans Health Administration

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans?

The VAMC in Memphis, Tennessee consists of one main campus located at 116 N. Pauline St., which includes a 12-bed Spinal Cord Injury Unit, and ten community based outpatient clinics (CBOC). It is a tertiary care facility classified as a Clinical Referral Level 1 Facility and one of the most complex medical centers in the VA system. It is a teaching hospital, providing a full range of patient care services, with state-of-the-art technology, as well as extensive education and research programs. Comprehensive primary, secondary, and tertiary health care is provided in areas of medicine, general cardiovascular and neurological surgery, psychiatry, physical medicine and rehabilitation, spinal cord injury, neurology, oncology, dentistry, and geriatrics. Specialized outpatient services are provided through general, specialty, and subspecialty outpatient clinics including a women's health center. Services are available to more than 206,000 Veterans living in a fifty-three county tri-state area (Tennessee, Arkansas, and Mississippi).

Agency contact information

Heather Spurr
Phone
615-349-0962
Email
Heather.Spurr@va.gov
Address
Memphis VA Medical Center
116 N. Pauline St.
Memphis, TN 38105
US

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