Medical Record Technician (Coder Inpatient)

Veterans Health Administration • Bay Pines, FL

2d • Onsite

About The Position

This position is in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System. The Medical Record Technician (Coder Inpatient) classifies medical data from patient health records in hospital and other clinical settings. The work covers complex inpatient facility and professional-service encounters and requires accurate coding based on documentation, current classification systems, regulatory requirements, and VA policies.

The coder reviews health records, assigns and sequences diagnosis and procedure codes, evaluates documentation, and supports accurate patient classification and reimbursement. The role also helps facility staff understand coding and documentation requirements, identifies incomplete or incorrect records and codes, and codes records from VA and non-VA sources, including inpatient admissions, surgical cases, professional services, and registry forms.

The position is scheduled Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is not authorized, and the position is not virtual. Relocation and recruitment incentives and permanent change of station benefits are not authorized. Employees must serve a one- or two-year trial period.

Requirements

• U.S. citizenship, subject to the stated exception for appointments when qualified citizens cannot be recruited.
• Proficiency in spoken and written English.
• Meet the applicable experience, education, or combination-of-education-and-experience qualification for the grade level.
• For the basic experience pathway: one year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format.
• Alternatively, meet the stated education or training pathways, including an associate degree in health information technology/management or related study with at least 12 semester hours in the field, or completion of an eligible coding training program.
• Possess an applicable AHIMA or AAPC Apprentice/Associate or Mastery Level certification, or an AHIMA or ACDIS Clinical Documentation Improvement certification, subject to the stated grandfathering provision.
• Meet the applicable grade-level experience, education, and competency requirements. GS-5 through GS-8 requirements include coding-system knowledge, health-record analysis and abstraction, documentation assessment, confidentiality law, coding accuracy, prioritization, communication, and coding problem-solving skills, with requirements varying by grade.
• Complete the required application steps, questionnaire, and online assessment.
• Register for Selective Service if required for males born after December 31, 1959.
• Complete background/security investigation, onboarding, identification, and application-document requirements.
• Participate in the seasonal influenza vaccination program as required for VA Health Care Personnel.
• Serve the applicable one- or two-year trial period.
• Meet physical requirements described in VA Directive and Handbook 5019.

Responsibilities

• Assign codes to documented inpatient facility and/or professional-service encounters across the full range of VAMC healthcare services.
• Apply medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and health-services principles to select appropriate codes.
• Monitor changes to regulatory and policy requirements affecting coded information and apply changes in a timely manner.
• Assist facility staff with documentation requirements and provide technical support concerning regulations, coding, reimbursement, workload, nomenclature, sequencing, and resident supervision.
• Verify that provider documentation is complete and supports coded diagnoses and procedures; report incorrect documentation or codes in the electronic patient health record.
• Use health-record applications and office software in daily work.
• Review codes abstracted for inpatient encounters identified by the VERA committee, determine whether requirements were followed, and correct coding as needed.
• Code inpatient professional-fee services for identified inpatient admissions in compliance with regulatory fraud and abuse guidelines and VA guidance.
• Code inpatient procedures reported in the VistA hospital system using current ICD and CPT guidelines and the encoder product suite; ensure procedures file to the appropriate Patient Care Encounter and add Anesthesia and Pathology codes for billable surgical cases.
• Review and code assigned fee-service Care in the Community inpatient encounters using documentation from non-VA facilities.
• Code diagnoses from paper forms for VA registries, including Agent Orange, Ionizing Radiation, Persian Gulf, and Prisoner of War registries.
• Review health records and abstract required medical, surgical, ancillary, demographic, social, and administrative data.
• Assign and sequence inpatient codes, including CC/MCC and POA indicators, to support accurate MS-DRG assignment.
• Communicate with clinical staff about coding and documentation issues, research and resolve coding problems, and correct system or processing errors.

Benefits

• Federal employees and their families have access to a comprehensive benefits package; specific benefit eligibility depends on position type.
• Selected applicants may qualify to receive credit toward annual-leave accrual for prior work or military service, subject to request and approval.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree