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Medical Records Technician (Coder)
Veterans Health Administration · Posted 105 days ago
Remote United States $29K – $73K Apply by Jun 29, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
Medical Record Technicians (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. This includes patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
What You'll Do
- →Major Duties Include: Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed.
- →Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.
- →Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing.
- →Uses skill and knowledge of the organization and structure of the patient health record to capture and justify code assignment.
- →Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
- →At the direction of the supervisor assists in orienting and instructing new personnel and/or students from affiliated health information or medical record technology programs.
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →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.
- →Selects and assigns codes from the current version of the International Classification of Diseases (ICD) Clinical Modification (CM), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- →Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) for the specialty and subspecialty health care services provided by the VAMC.
- →Conducts re-reviews of codes abstracted for outpatient 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 outpatient 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.
- →Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
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.
- ✓You may be required to serve a probationary period.
- ✓Subject to background/security investigation.
- ✓Selected applicants will be required to complete an online onboarding process.
- ✓Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- ✓Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.
- ✓IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
- ✓Note: Only education or degrees recognized by the U.S.
- ✓Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment.
- ✓You can verify your education here: http://ope.ed.gov/accreditation/.
- ✓If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.
Personality Fit
Job ID: 05faec73-a29d-45b9-9793-f702c508f5b6
Posted via USAJobs