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LEAD MEDICAL RECORDS TECHNICIAN
Veterans Health Administration · Posted 1 days ago
Remote United States $64K – $84K Apply by Jun 16, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) section at the Durham VA Healthcare System. 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.
What You'll Do
- →The duties listed above is not inclusive of all the duties that may be associated with this position.
- →Basic Functions: Assigns codes to documented patient care encounters (inpatient and/or outpatient) covering the full range of health care services provided by the VAMC.
- →Patient encounters are often complicated and complex requiring extensive coding expertise.
- →Applies advanced knowledge of medical terminology, anatomy & 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 several 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).
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
- →Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- →Patient health records may be paper or electronic.
- →The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
- →Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
- →Lead Functions: Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities.
- →Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies.
- →Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill and ability to perform the full range of routine and non-routine responsibilities required.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓To be considered for this position, you must complete all required steps in the process.
- ✓In addition to the application and questionnaire, this position requires an online assessment.
- ✓The online assessment measures critical general competencies required to perform the 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 dentification 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.
Personality Fit
Job ID: 5c29318f-16d8-40ea-8e8d-4db0848ab7f1
Posted via USAJobs