Medical Records Technician (Coder - Inpatient / Outpatient)

About the role

This position is in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center located in Milwaukee, Wisconsin. VA Medical Center.

What you will do

• The Medical Records Technician (Coder-Inpatient/Outpatient) is located in the Health Information Management (HIM) section at the Clement J.
• Zablocki VA Medical Center.
• Medical Records Technicians (Coder-Inpatient/Outpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, 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 Disease(ICD), Current Procedural Terminology(CPT) and the Healthcare Common Procedure Coding System (HCPCS).
• Duties Include but are not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient/outpatient facility and/or professional services.
• Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of Inpatient/Outpatient settings and specialties.
• Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient/outpatient professional services.
• Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Ensure audit findings have been corrected and refiled.
• Use various computer applications to abstract records, assign codes, and record and transmit data.
• MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Work Schedule: Monday - Friday 8:00am - 4:30pm Compressed/Flexible: Not authorized.
• Telework: Available Functional Statement #: 10482F, 10483F, 10484F, 10485F, 10486F Relocation/Recruitment Incentives: Not authorized.
• Permanent Change of Station (PCS): Not authorized.
• PCS Appraised Value Offer (AVO): Not authorized.

Requirements

• You must be a U.S. Citizen to apply for this 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 (***).
• 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.

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: ***

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: ***

How you will be evaluated

Area of Consideration - Eligible applications will be reviewed and referred in the following order: 1. Current permanent VA employees of the facility. 2.

All other VA employees. 3. All other Federal employees.

4. All other applicants.

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.

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.

Documents you must provide

• Long-form resume/Curriculum vitae (CV) The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc. Cover Letter DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) Long-form resume/Curriculum vitae (CV) Other (1) Separation Notice (RIF) SF-15 SF-50/ Notification of Personnel Action Transcript

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.

After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service.

HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.

HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.

HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

Additional information

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.

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.