Job Listing
Medical Records Technician (Coder Outpatient)
Veterans Health Administration · Posted 1 days ago
Hybrid Durham, NC $58K – $76K Apply by Jul 6, 2026 Medical Records Technician ESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is in the Health Administration Service section at the Durham VA 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
- →The duties listed above is not inclusive of all the duties that may be associated with this position.
- →Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC.
- →Patient encounters are often complicated and complex requiring extensive coding expertise.
- →Applies advanced 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.
- →Selects and assigns codes from the 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.
- →Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
- →Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- →Patient health records may be paper or electronic.
- →The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
- →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.
- →Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
- →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.
- →Codes inpatient professional fee services for identified inpatient admissions.
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 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.
- ✓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: 5b85b121-e631-48e8-acf0-c6f475359b8d
Posted via USAJobs
Related Jobs
Today
Federal Aviation Administration