Job Listing
Medical Records Technician (Clinical Documentation Improvement Specialist Outpatient and Inpatient)
Veterans Health Administration · Posted 1 days ago
RemoteUnited States$53K – $100KApply by Jun 2, 2026Medical Records TechnicianESFJESTJISFJISTJHealthcareTrades
Apply for this job →About the Role
This position is located in the Health Information Management (HIM) section at the VA Long Beach 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. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
What You'll Do
- →Duties include but are not limited to: Responsible for reviewing the overall quality and completeness of clinical documentation.
- →Applies comprehensive 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.
- →Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
- →Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
- →Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
- →Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
- →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.
- →Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
- →Ensures provider documentation is complete and supports the diagnoses and procedures coded.
- →Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- →Reports incorrect documentation or codes in the electronic patient health record.
- →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.
- →Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
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 (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.
- ✓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.
- ✓Note: Only education or degrees recognized by the U.S.
Personality Fit
Job ID: ed78445c-935b-477c-8426-ca9293e48b00
Posted via USAJobs