Medical Records Technician (CDIS - Inpatient)

Veterans Health Administration

United States

Remote

USD 62,000 - 80,000

Full time

4 days ago

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Benefits offered by this job

Remote work eligibility

Job summary

Veterans Health Administration in the United States is seeking a Medical Records Technician (CDIS - Inpatient) to classify and abstract health data in patient records. The role supports coding for ICD, CPT, and HCPCS, and provides education on documentation to clinical staff. It is fully remote nationwide with regular federal benefits.

The position emphasizes accurate coding, documentation quality, and collaboration with clinical teams to ensure complete patient records for healthcare services.

Qualifications

Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
I have knowledge of anatomy, physiology, pathology, and pharmacology for interpreting health records.
Ability to collect and analyze data and present results.

Responsibilities

Demonstrates expertise in ICD, CPT, and HCPCS coding.
Reviews the quality and completeness of clinical documentation.
Educates providers on documentation and coding requirements.
Ensures accurate reflection of patient care in health records.

Skills

ICD coding knowledge

CPT coding knowledge

HCPCS coding knowledge

Education on documentation

Verbal and written communication

Education

Knowledge of anatomy & physiology, pathology, pharmacology

Tools

Coding guidelines & standards

Job description

Medical Records Technician (CDIS - Inpatient)

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

MRTs (CDIS - Inpatient) 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.

Key Responsibilities

Total Rewards of a Allied Health Professional Duties of the Medical Records Technician (CDIS-Inpatient) include, but are not limited to: Demonstrates 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. Reviews the overall quality and completeness of clinical documentation.

Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries. Reviews clinical documentation and provides education to clinical staff on outpatient episodes of care.

Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.

Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.

Consults with the professional staff for clarification of conflicting or ambiguous clinical data. Adheres to accepted coding practices, guidelines, and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or 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.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator.

Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.

Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate. Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.

Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management. Work Schedule: Monday - Friday, 8:00 am to 4:30 pm, subject to change based on the needs of the facility.

Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Remote: The position is remote work eligible and is exempted from returned to office requirements. Remote exempted positions are reviewed annually and do not imply permanent remote work status.

Functional Statement #: 598-01373F Permanent Change of Station (PCS): Not Authorized

Requirements & Education

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii.

Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. iv.

Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS.

They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators. vii. Knowledge of severity of illness, risk of mortality, and complexity of care. viii. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.

The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. Preferred Experience: Prefer at least 2 years of experience. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-09.

Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, puling, and pushing. May require required wearing personal protective equipment and undergo annual TB screening or testing as conditions of employment.

Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated. However, the work environment requires someone with ability to handle several tasks at once in sometimes stressful situations. 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, 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 2026-10-19.

Who is eligible to apply?

This position is open under the 'Fed Competitive' hiring path.