Job Listing
Medical Records Technician (Coder Outpatient and Inpatient)
Veterans Health Administration · Posted 7 days ago
Remote United States $56K – $73K Apply by Jun 5, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is in the Health Information Management section at the Richard L. Roudebush VA Medical Center. MRTs (Coder) analyze, abstract, and classify medical data from patient health records across hospital and physician-based settings, including offices, group practices, multi-specialty clinics, and specialty centers. They assign ICD, CPT, and HCPCS codes and may also provide staff education on coding and documentation.
What You'll Do
- →Duties: Identifies the 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).
- →Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff.
- →All diagnoses and procedure codes are selected from the current version of the ICD coding system.
- →Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) 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.
- →Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.
- →Establishes the primary and secondary diagnosis and procedure codes for outpatient professional and technical fee 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.
- →Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; uses established processes to communicate potential billing issues to Consolidated Patient Account Center (CPAC) staff.
- →Codes all identified surgical procedures; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; adds Anesthesia and Pathology codes for all billable surgical cases, which may involve creating the encounters.
- →Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay (30+ days) admissions to reflect all patient conditions and care up to the census date or to the requested billing date.
- →May be required to review and enter coded data from paid Community Care claims using documentation (e.g., hard-copy claims) obtained from non-VA facilities.
- →May code diagnoses for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
- →Work Schedule: Monday - Friday.
- →Employees are scheduled for an 8-hour working shift and may choose a start time anytime at or after 7:00 AM ET, provided their workday concludes no later than 5:00 PM ET.
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.
- ✓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.
- ✓Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers.
- ✓An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment 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: bd5b543b-fc52-43e8-b6fc-f83f78eca5b8
Posted via USAJobs