Lead Medical Records Technician (Coder)

Ativesite

United States

Remote

USD 62,000 - 80,000

Full time

47 hours ago

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Benefits offered by this job

Remote work

Telework eligible

Job summary

Ativesite is recruiting for a Lead Medical Records Technician (Coder) within the Department of Veterans Affairs, Health Information Management (HIM). The role is remote and requires coding of inpatient/outpatient encounters using ICD-CM, CPT, and HCPCS to support research, reimbursement, and care quality at the VA system.

Responsibilities include reviewing electronic health records, ensuring complete data capture, and guiding staff in ICD/CPT coding practices.

Qualifications

Proficient in ICD-CM, CPT and HCPCS coding.
Strong attention to detail and accuracy in data capture.
Knowledge of health information management practices and coding guidelines.

Responsibilities

Code patient encounters using ICD- CM, CPT, and HCPCS.
Review electronic health records to ensure complete and accurate data capture.
Ensure documentation supports diagnoses and procedures for quality, reimbursement and reporting.

Skills

Medical coding

Attention to detail

ICD-CM CPT HCPCS knowledge

Tools

EHR systems

Job description

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

This position is located in the Health Information Management (HIM) section at the Loma Linda, CA VA Medical Center. 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.

Key Responsibilities

PLEASE NOTE: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S.

Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements. Any selected candidate must live within 50 miles of a VA Medical Center.

Duties include but are not limited to: 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) 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 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 Ensures provider documentation is complete and supports the diagnoses and procedures coded Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities.

Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies.

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 Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources Identifies training needs of individuals based on productivity and accuracy reports, rejects from billing, and spot checks.

Makes recommendations to Supervisor concerning disciplinary actions due to insufficient performance and identifies continuing education needs Has constant interaction with health care providers, evaluating and communicating with the expectation on improving health record documentation Other duties as assigned Work Schedule: Monday - Friday 7:30 a.m. - 4:30 p.m.

(Tour of duty is based on organizational needs) Telework: This position is telework eligible but may be required to return to the office permanently at a later date. Virtual: This is a virtual position. Functional Statement #:00000 Financial Disclosure Report: Not required

Requirements & 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 is the application deadline?

Applications close on 2026-11-20.

Who is eligible to apply?

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