Medical Records Technician (Coder - Inpatient / Outpatient)

U.S. Department of Veterans Affairs; United States; Remote; USD 36,000 - 73,000; Full time

Job summary

U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coder) for the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center, Milwaukee, WI.

This fully remote role supports inpatient and outpatient coding across the Veterans Health Administration. Responsibilities include coding using ICD-10-CM/PCS, CPT, and HCPCS, abstracting data from health records, and ensuring accurate DRG assignments and billing compliance.

Qualifications

• Experience coding medical records using ICD, CPT and HCPCS.
• Ability to abstract and classify data from health records.
• Familiarity with DRG assignment and encoder software.

Responsibilities

• Code inpatient/outpatient records using ICD-CM/PCS, CPT and HCPCS.
• Abstract clinical data to support accurate coding and documentation.
• Review health records to assign DRGs and professional codes.

Job description

Medical Records Technician (Coder - Inpatient / Outpatient)

• 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 Clement J. Zablocki VA Medical Center located in Milwaukee, Wisconsin. VA Medical Center.

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 2026-11-13.

How many openings are available?

There are 17 openings for this position.

Who is eligible to apply?

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