[Hiring] Medical Records Technician @Salem VA Medical Center

Role Description

This position is part of the Health Information Management (HIM) Service at the Salem VA Healthcare System. It focuses on the specialized work of Medical Records Technicians (Coders), who are responsible for accurately classifying medical data found in patient health records. Medical Records Technicians (Coders) interpret clinical information from hospital and physician-based settings and apply standardized coding systems, including ICD, CPT, and HCPCS.

Responsibilities

• Reviews clinical documentation for completeness, accuracy, clarity, and specificity through concurrent and retrospective inpatient record review.
• Ensures documentation supports all monitored, evaluated, assessed, and treated conditions, accurately reflecting SOI, ROM, and resource use.
• Performs concurrent CDI reviews to improve documentation while the patient is still admitted.
• Applies knowledge of anatomy, physiology, disease processes, treatments, diagnostics, medications, and procedures to support accurate documentation and code selection.
• Collaborates with clinical staff using written, verbal, or electronic queries to clarify ambiguous or incomplete documentation.
• Provides education to providers on accurate, complete inpatient documentation and its impact on coding, quality, reimbursement, and funding.
• Reports incorrect or insufficient documentation in the electronic health record.
• Follows inpatient coding guidelines to verify appropriate diagnosis and procedure code selection and maintains compliance with regulatory updates.
• Uses EHR applications, encoders, CDI software, and tools such as Outlook, Excel, Word, and Access.
• Develops and delivers documentation training sessions, workshops, and briefings for clinical and HIM staff.
• Assists in developing guidelines for data consistency, compatibility, and compliance to support clinical, administrative, and financial accuracy.
• Provides expertise on documentation requirements, privacy, confidentiality, informed consent, liability issues, and reporting mandates.

Work Schedule: Monday - Friday 8:00am - 4:30pm

Remote: This position is designated as remote. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs).

Virtual: This is not a virtual position.

Functional Statement #: 000000

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

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.
• 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: Proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• Education: An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records).
• 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.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA MUST have either:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Grade Determination: In addition to the Basic Requirements above, candidates must also meet any additional requirements to include KSAs based on grade assignment below.
• GS-09 Experience: One year of creditable experience equivalent to the GS-8 grade level of an MRT (Coder-Inpatient); OR an associate's degree or higher, and three years of experience in clinical documentation improvement.
• Demonstrated KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology; Knowledge of anatomy and physiology, pathophysiology, and pharmacology; Ability to collect and analyze data; Knowledge of regulations that define healthcare documentation requirements; Extensive knowledge of coding rules and regulations.

Physical Requirements

See VA Directive and Handbook 5019.