Medical Records Technician (Coder)

U.S. Department of Veterans Affairs

United States

Remote

USD 36,000 - 73,000

Full time

3 days ago

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Benefits offered by this job

Remote work

Job summary

U.S. Department of Veterans Affairs seeks a Medical Records Technician (Coder-Inpatient/Outpatient) within the Health Information Management (HIM) section at Clement J. Zablocki VA Medical Center.

You will classify, abstract, and code health records using ICD, CPT, and HCPCS for inpatient/outpatient settings. Responsibilities include deriving accurate diagnoses and procedures, ensuring DRG alignment, and collaborating with clinicians to resolve data ambiguities.

Qualifications

Experience coding inpatient/outpatient medical records.
Expertise in ICD, CPT, and HCPCS coding systems.

Responsibilities

Code from current ICD-CM, ICD-PCS, CPT/HCPCS for inpatient/outpatient services.
Review and abstract clinical data to support assigned codes.
Assign codes to ensure accurate DRG and professional service CPT/HCPCS.
Consult with clinical staff for clarification of data.

Skills

Medical coding

ICD coding

CPT/HCPCS coding

Education

Federal education verification

Tools

Encoder software

Job description

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

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans?

Key Responsibilities

The Medical Records Technician (Coder-Inpatient/Outpatient) is located in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center. Medical Records Technicians (Coder-Inpatient/Outpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, 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 Disease(ICD), Current Procedural Terminology(CPT) and the Healthcare Common Procedure Coding System (HCPCS). Duties Include but are not limited to: Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient/outpatient facility and/or professional services.

Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of Inpatient/Outpatient settings and specialties. Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.

Comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient/outpatient professional services.

Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. Ensure audit findings have been corrected and refiled. Use various computer applications to abstract records, assign codes, and record and transmit data. MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.

Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. Work Schedule: Monday - Friday 8:00am - 4:30pm Compressed/Flexible: Not authorized. Telework: Available Functional Statement #: 10482F, 10483F, 10484F, 10485F, 10486F Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized. PCS Appraised Value Offer (AVO): Not authorized.

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 $36409 – $72644/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 2026-11-11.

How many openings are available?