Job Listing
Med Rec Tech (Med Coder)
Veterans Health Administration · Posted 17 days ago
Remote United States $42K – $83K Apply by Sep 21, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
Medical Records Technician (Coder - Outpatient and Inpatient) analyzes and abstracts patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, he/she must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).
What You'll Do
- →This position is in the Health Information Management Service (HIMS) at the VA Western New York Health Care System (VAWNYHCS).
- →MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.
- →GS-4 Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services.
- →Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding.
- →Incumbent with instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
- →GS-5 Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement.
- →Links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.
- →GS-6 Assigns codes to documented patient care encounters (inpatient and outpatient) for one or more specialty and subspecialty health care services provided by the VAMC Incumbent has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
- →Incumbent selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
- →Incumbent monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment.
- →Incumbent at the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs.
- →GS-7 Receives minimal monitoring.
- →MRTs (Coder) perform a combination of inpatient and outpatient coding duties Selects and assigns codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.
Requirements
- ✓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.
Personality Fit
Job ID: e5fb63a2-088c-4d62-be56-efca238bd165
Posted via USAJobs