Internship Medical Data Encoder Jobs in Gainesville, FL

Summary
The Medical Record Technician (Coder) will work in the Health Information Management Section (HIMS) of the Medical Administration Service (MAS). Two vacancies available at the Malcom Randall VA Medical Center as well as the Jacksonville VA North Clinic and will be responsible for performing a quality review of patient care documents and assigning codes specific for the type of care provided.
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Duties
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Total Rewards of a Allied Health Professional

• Assign diagnosis and procedure codes to the most basic and routine inpatient admissions and outpatient encounters. Develop skill and knowledge of medical record coding. Has basic knowledge of medical terminology, anatomy & physiology, and pathophysiology.
• Learn to select diagnosis and/or procedure codes based on the accepted coding practices, guidelines, conventions and policies with guidance from a senior coder or supervisor.
• Identifies the principal diagnosis and/or principal procedure for every inpatient admission.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate code to ensure ethical, accurate, and complete coding.
• Reviews medical record documentation to abstract all relevant clinical, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder.
• Assist in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs with the direction of the supervisor.
• Work within a team environment, supporting peers, handle multiple tasks, meet goals, and work with frequently changing projects and deadlines.
• Utilize advanced knowledge of encoder software and use a variety of Windows based applications in day to day activities and duties, such as Outlook, Excel, and Word. Performs other related duties as assigned.

Work Schedule: 8am to 4:30pm, Monday through Friday
Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).
Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Telework: 3 plus days per pay period.
Virtual: This is not a virtual position.
Functional Statement #: GS4-50188F, GS5-50187F, GS6-50191F, GS7-50192F, GS8-50193F
Requirements
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Conditions of employment

• 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 (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.
• 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.
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.
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 chapter 3, section A, paragraph 3g, this part.)
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.
Grade Determinations:
Medical Records Technician, GS-4
Experience or Education. None beyond basic requirements.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-5
Experience. One year of creditable experience equivalent to the next lower grade level; OR,
Education. Successful completion of a bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information management or technology.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the KSAs found in the qualification standards and/or the assessment questionnaire.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-6
Experience. One year of creditable experience equivalent to the next lower grade level.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the KSAs found in the qualification standards and/or the assessment questionnaire.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-7
Experience. One year of creditable experience equivalent to the next lower grade level.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the KSAs found in the qualification standards and/or the assessment questionnaire.
Medical Records Technician (Coder-Outpatient and Inpatient), GS-8
Experience. One year of creditable experience equivalent to the next lower grade level.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

Assignment. This is the journey level for this assignment. MRTs (Coder) at this level perform the full scope of inpatient and outpatient coding duties. MRTs (Coder) select and assign codes from current versions of ICD CM, PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD CM and PCS codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of DRGs. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnosis and complications, and CPT/HCPCS codes for surgeries, procedures, evaluation and management services, and inpatient professional services. Other responsibilities can be found in the qualification standards.
Preferred Experience: Inpatient and outpatient experience, coding credentials and knowledge of anatomy and physiology/disease processes, documentation queries. Knowledge of coding language such as ICD-10-CM PCS, CPT HCPCS, and ICD-10.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
The full performance level of this vacancy is GS-8. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-8.
Physical Requirements: The work is mainly sedentary in nature. Typically, the Employee may sit to do the work. There may be some walking, standing, bending, and climbing step(s) to conduct meetings or perform quality assurance activities.
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: 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/.
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