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Medical Records Technician (Coder- Inpatient)
Veterans Health Administration · Posted 19 days ago
Remote United States $36K – $73K Apply by Jun 30, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder-Inpatient) position. The Medical Records Technician (Coder-Inpatient) is located in the Health Information Management Services (HIMs) section within Patient Care Administrative Service.
What You'll Do
- →Major duties of the Medical Records Technician (Coder - Inpatient) include, but are not limited to: Reviewing record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder).
- →Use various computer applications to abstract records, assign codes, and record and transmit data.
- →They ensure audit findings have been corrected and refiled.
- →Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty.
- →Has basic knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
- →Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
- →Coding systems include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- →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.
- →Maintains current knowledge of regulatory and policy requirements affecting coded information.
- →Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data.
- →Insures provider documentation supports the diagnoses and procedures coded.
- →Consults with a more senior coder or the supervisor to resolve issues related to conflicting or questionable clinical documentation.
- →Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment.
- →Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
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 identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- ✓Must pass pre-employment physical evaluation.
- ✓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.
Personality Fit
Job ID: 38ee0488-ddd5-4291-98b0-4677ea2e5b3c
Posted via USAJobs