Lead Medical Records Technician (Coder)

U.S. Department of Veterans Affairs; United States; Remote; USD 62,000 - 80,000; Full time

Job summary

U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coder) to work remotely anywhere in the U.S. within the Health Information Management (HIM) section at the Lt. Col.

Luke Weathers, Jr. VA Medical Center. The MRT (Coder) will classify medical data from patient health records using ICD, CPT, and HCPCS and may educate others on coding and documentation. The role requires expertise in imaging and coding standards, with lead MRTs occasionally guiding others, auditing data,

Responsibilities

• Analyze and abstract patients' health records and assign ICD, CPT, and HCPCS codes.
• Lead MRTs (Coder) review coding, provide guidance, and coordinate workflow to improve accuracy.
• Ensure coding accuracy and compliance with coding rules and regulations.
• Train new coders and students on ICD and CPT coding and EHR use.

Job description

• Department: Department of Veterans Affairs
• Location: Anywhere in the U.S. (remote job)

This position is in the Health Information Management (HIM) section at the Lt. Col. Luke Weathers, Jr. VA Medical Center. Medical Records Technicians (MRT) (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.

Key Responsibilities

These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation.

For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Lead MRTs (Coder) must be able to perform all duties of a MRT (Coder).

Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate, prepare, and maintain various reports, and analyze data; and may also coordinate, assign, and monitor workflow. They provide input for performance evaluations and hiring.

Duties include but are not limited to the following: Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.

Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), 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. 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 electronic 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. 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. Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill, and ability to perform the full range of routine and non-routine responsibilities required.

Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture. Reviews, audits, trains, monitors, and completes special assignments within specified time frames. Work Schedule: Monday - Friday; 7:30 am - 4:00 pm Telework: Not Available. Remote: This position currently has a mid-term Return to Office (RTO) extension of 180 days.

Please note that this extension is subject to change. Candidates may be required to return to the office if agency policy is updated or if the exemption is not extended. Must be able to travel within 50 miles of a VA Facility if remote status is cancelled. Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.

Requirements & Education

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. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $61722 – $80243/yr.

Is this position remote or telework eligible?

Yes, this position is fully remote.

What security clearance is required?

This position requires a Other security clearance.

What is the application deadline?

Applications close on 2026-10-26.

Who is eligible to apply?

This position is open under the 'Public' hiring path.