Medical Records Technician (Coder-Outpatient)

Summary

The John D. Dingell VA Medical Center in Detroit, Michigan is recruiting for a Medical Records Technician (MRT) (Coder-Outpatient) that will function in the Health Information Management (HIM) service. MRTs (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.

Duties

Total Rewards of a Allied Health Professional Major duties include, but are not limited to: Assigns codes to documented patient care encounters covering the full range of health care services provided by the VA Medical Center (VAMC). Applies advanced knowledge of medical terminology, anatomy and 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 serval 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). Adheres to coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and recourse needs. 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 patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure completed 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. Reports incorrect documentation or codes in the electronic patient health record. Utilizes the facility computer system and software applications to correct code, abstract, record, and transmit data to the national VA database in Austin. VA and federal employees must submit a SF-50 Notification of Personnel Action dated in 2026 to receive their claimed eligibility. Failure to submit required SF-50 dated in 2026 will result in your disqualification. This position is also open to US Citizens with CBSR-13065594-26-CB. Please ensure you are applying to the correct announcement based on your area of consideration. Note: there is an applicant count for the US Citizen announcement - it may be removed prior to closing date if applicant count is reached. Work Schedule: Monday - Friday, 8:00am - 4:30pm. EST. This position requires the candidate to work in the Eastern Time Zone (ET) and maintain a standard business day schedule. All work, meetings, and collaboration must be conducted during these hours. Candidates must be available to respond to work-related communications and participate in scheduled activities within this time frame. Additional work schedules may become available at a future date. This job opportunity announcement may be used to fill additional vacancies. Telework: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Applicants must live within 50 miles of a VA Medical Center as they may be subject to the RTO order. Virtual: This is not a virtual position. Functional Statement #: 91153A, 91154A, 91155A, 91156A, and 91157A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized VA Healthcare System advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.

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/or 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: 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) Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grandfathering Provision. May q