- You must be a U.S. Citizen to apply for this job.
- All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
- 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). 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 examination.
- 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.
BASIC REQUIREMENTS
- Citizenship. Citizen of the United States. (Non-citizens may 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 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:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC.
(2) Mastery Level Certification through AHIMA or AAPC.
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply:
- Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
- Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
- MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
- MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
- Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.
GRADE REQUIREMENTS
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient)), GS-9 Experience
- One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder-Outpatient); OR,
- 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); OR,
- Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR,
- Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement.
****CERTIFICATION**** Employees at this level MUST have either a Mastery Level Certification or a Clinical Documentation Improvement Certification.
- Current Mastery Level Certifications include Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).
- Current Clinical Documentation Improvement Certifications include Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
Demonstrated Knowledge, Skills, and Abilities (KSAs) - In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record.
- Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
- Ability to establish and maintain strong verbal and written communication with providers.
- Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
- Extensive knowledge of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS).
- Knowledge of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.
- Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
VA Handbook 5005/122 Part II, Appendix G-57
Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
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: http://ope.ed.gov/accreditation/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.
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.
Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
You will be evaluated for this job based on how well you meet the qualifications above.
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.
To apply for this position, you must provide a complete Application Package which includes:
Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.
Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.
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
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DD-214/ Statement of Service
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Disability Letter (Schedule A)
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Disability Letter (VA)
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Resume
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Professional Certification
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Resume
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Separation Notice (RIF)
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SF-15
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SF-50/ Notification of Personnel Action
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Transcript
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
