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Medical Records Technician (Coder-Inpatient)
Veterans Health Administration · Posted 60 days ago
Remote United States $36K – $73K Apply by Aug 18, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
The Medical Records Technician (Coder - Inpatient) position is located in the Health Information Management Services (HIMS) section within the Health Administration Service at the Charlie Norwood VA Medical Center. The MRT (Coder) is responsible for analyzing and abstracting health record data and assigning alpha-numeric codes for each diagnosis and procedure using current clinical classification systems for inpatient facility and/or professional services. THIS IS A REMOTE POSITION
What You'll Do
- →Total Rewards of a Allied Health Professional Major duties and responsibilities include, but not limited to: Functions: Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VA Medical Center.
- →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.
- →Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- →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.
- →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.
- →Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin.
- →Uses a variety of computer applications in day to day activities and duties.
- →Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs.
- →Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
- →Specific Functions: Identifies principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
- →Conducts reviews of codes abstracted for inpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
- →Codes inpatient professional fee services for identified inpatient admissions.
- →Establishes the primary and secondary diagnosis and procedure codes for inpatient professional encounters 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.
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 health 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: a18800e3-7347-4e5e-980b-09385c50e81f
Posted via USAJobs