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Medical Records Technician (Coder)
Veterans Health Administration · Posted 17 days ago
Remote United States $41K – $81K Apply by Sep 18, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) section at the Edward Hines Jr. VA Hospital. MRTs (Inpatient 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
- →Duties: Duties and responsibilities of this position include, but are not limited to the following: Basic Functions Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the Edward Hines, VAMC.
- →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).
- →Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the Edward Hines, 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.
- →Insures provider documentation is complete and supports the diagnoses and procedures coded.
- →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.
- →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, 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.
- →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.
- →Specific Functions 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).
- →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.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
- ✓Applicants who refuse to be tested will be denied employment with VA.
- ✓Selective Service Registration is required for males born after 12/31/1959 Subject to background/security investigation Pre-employment physical required 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) As a condition of employment for accepting this position, you will be required to serve a 1-year probationary period 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 probationary period or trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.
- ✓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: c6c6f9a3-408b-4688-a4de-94fa2f812fe3
Posted via USAJobs