Medical Records Technician (Coder - Inpatient / Outpatient)

Veterans Health Administration • West Palm Beach, FL

7h • Onsite

About The Position

The Medical Records Technician (Coder - Inpatient / Outpatient) works in the Health Information Management Service at the West Palm Beach VA Medical Center. The role performs inpatient and outpatient coding to support accurate clinical documentation, workload capture, reimbursement, reporting, and healthcare data integrity. This is an on-site position; the employee must live within or be willing to relocate within commuting distance of the duty location.

The technician reviews, analyzes, and abstracts patient health records and assigns ICD, CPT, and HCPCS codes for medical, surgical, diagnostic, and professional services. The role requires knowledge of medical terminology, anatomy and physiology, disease processes, coding guidelines, and regulatory requirements. The coder works independently to ensure coding accuracy and compliance with national coding standards and VA policies, resolves coding issues, and queries providers when documentation is incomplete or ambiguous. The position supports accurate patient records, healthcare data, workload reporting, reimbursement, utilization review, and organizational performance measures.

The schedule is 8:00 a.m. to 4:30 p.m., Monday through Friday. Telework is not available, and the position is not virtual. The full performance level is GS-8. The work is primarily sedentary and involves extended periods sitting at a desk and working with computers, with some walking and standing for meetings or travel to meetings and conferences. No special physical effort is required.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Proficiency in written and spoken English.
• One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format; or qualifying education or training, including specified combinations of education and experience.
• Required MRT (Coder) certification: Apprentice/Associate Level or Mastery Level certification through AHIMA or AAPC, or Clinical Documentation Improvement certification through AHIMA or ACDIS; a stated grandfathering provision may apply to qualifying current VHA employees.
• For GS-08: one year of creditable experience equivalent to the next lower grade level.
• For GS-08: ability to analyze health records, identify pertinent diagnoses and procedures, and evaluate documentation adequacy, including understanding record content, terminology, comments, and disease processes/pathophysiology.
• For GS-08: ability to perform the full scope of outpatient coding and inpatient facility coding, including applicable surgical cases, diagnostic studies and procedures, encounters, discharges, and professional services.
• For GS-08: skill in interpreting and adapting health-information guidelines that are incomplete or insufficiently specific, and using judgment when completing assignments with incomplete or inadequate guidance.
• Must pass a pre-employment physical examination and, if tentatively selected for a testing-designated position, urinalysis screening for illegal drug use.
• Subject to background/security investigation and completion of the online onboarding process and application requirements.
• Must participate in the seasonal influenza vaccination program as a VA Health Care Personnel requirement.
• Must serve a one- or two-year trial period, subject to written certification for continued employment upon its completion.
• Must live within or be willing to relocate within commuting distance of the duty location.
• Male applicants born after December 31, 1959, must meet Selective Service registration requirements.
• Must provide acceptable identification for pre-employment requirements; from May 7, 2025, non-REAL-ID-compliant driver's licenses or state identification cards cannot be used as acceptable employment identification.

Responsibilities

• Review inpatient and outpatient health records to identify diagnoses, procedures, and services for coding assignment.
• Assign accurate ICD, CPT, and HCPCS codes in accordance with applicable coding guidelines and regulations.
• Analyze clinical documentation to ensure code selection is supported and compliant.
• Abstract and enter coded data into automated health record and coding systems.
• Identify, interpret, and code complex medical and surgical conditions, treatments, and procedures.
• Query providers to clarify incomplete, conflicting, or ambiguous documentation.
• Review provider documentation to ensure coding and reimbursement requirements are met.
• Resolve coding edits, discrepancies, and reimbursement-related issues.
• Maintain productivity and quality standards while meeting established workload deadlines.
• Use VistA, CPRS, encoder software, and other coding applications to perform coding and abstraction duties.
• Assist clinical staff with coding and documentation guidance and requirements.
• Support healthcare data collection, reporting, research, compliance reviews, and organizational performance initiatives.

Benefits

• Federal employee benefits package; eligibility depends on position type and other factors.
• Selected applicants may qualify for credit toward annual leave accrual based on prior work or military service, subject to request and approval before appointment and not guaranteed.

What This Job Offers

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