Lead Medical Records Technician (Coder-Inpatient)

Usajobs; United States; Remote; USD 80,000 - 110,000; Full time

Job summary

Department of Veterans Affairs seeks an Inpatient Lead Coder to act as subject matter expert for inpatient coding guidelines, policies, and regulatory requirements for inpatient health records.

This role will supervise ICD-10-CM/PCS coding, MS-DRGs/APR-DRGS, audits, and training of the inpatient coding team; remote work within 50 miles of a VA Medical Center, with potential on-site duties as needed.

Qualifications

• U.S. citizen required; Selective Service registration for males born after 1959.
• Proficient in written and spoken English; background/security check required.
• Remote work option within 50 miles of a VA Medical Center; on-site as needed.

Responsibilities

• Perform and/or review ICD-10-CM/ICD-10-PCS coding for inpatient records.
• Conduct regular audits to ensure accuracy, compliance, and proper reimbursement.
• Provide direction, training, and workload coordination for inpatient coding staff.
• Develop training material and address coding inquiries from providers and staff.

Skills

ICD-10-CM coding

ICD-10-PCS coding

MS-DRGs/APR-DRGS knowledge

Regulatory compliance

Mentoring/training

Tools

Encoder software

Job description

Summary

The Inpatient Lead Coder must be able to perform all duties of an MRT (Coder). They serve as a subject matter expert and resource for coding staff and other health care professionals regarding coding guidelines, policies, and regulatory requirements for inpatient health records.

Major Duties

Temporarily eligible for Remote work within 50 miles of a VA Medical Center. May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review. Duties include but are not limited to the following: Performs and/or reviews the assignment of International Classification of Diseases, Clinical Modification (ICD-10-CM), ICD-10-PCS procedure codes, and Diagnosis Related Grouping (MS-DRGs or APR-DRGS) based on documentation within inpatient medical records. Conducts regular internal audits of inpatient coding to ensure accuracy, compliance with regulatory and VA policies, and appropriate reimbursement. Collaborates with providers, clinical documentation, resolve coding discrepancies, and support accurate clinical documentation. Provides direction and support to the inpatient coding team, assists in workload distribution, and acts as a coordinator for inpatient coding-related Initiatives. Orient and instruct new coding personnel and/or students on coding, abstracting and use of the electronic health recorder and encoder software. Ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection. Monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs. Develop coding training material and present a curriculum encompassing ongoing training initiatives. Provide assistance with coding inquiries from providers, MRTs (Coder), billers and other faculty staff. Other duties as assigned Work Schedule: Monday-Friday Administrative Hours Telework: Not applicable, this is a remote position. Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs). Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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/.

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. 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.

Evaluations

Area of Consideration: Eligible applications will be reviewed and referred in the following order: 1. Current permanent VA employees of the facility. 2. All other VA Employees IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Required Documents

To apply for this position, you must provide a complete Application Package which includes: Long-form resume/Curriculum vitae (CV) Professional Certification SF-50/ Notification of Personnel Action The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc. Cover Letter License Long-form resume/Curriculum vitae (CV) **Highly Recommend** Write to the Knowledge, Skills, and Abilities (KSAs) on a separate document - KSAs are found under qualification/grade requirements in the announcement.** Performance Appraisal Professional Certification SF-50/ Notification of Personnel Action Transcript Veterans' preference does not apply for internal or other current permanent Federal agency employees.

Other Information

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.