Lead Medical Records Coder (Medical Records Technician)

Quick Facts

• Role: Lead Medical Records Coder (Medical Records Technician - Coder)

• Work model: Remote/virtual telework eligible; may require return to a VA office

• Schedule: Monday–Friday, 7:30 a.m.–4:30 p.m.

Description

Lead medical records coding work in a hospital/physician setting to classify diagnoses and procedures for research, epidemiology, outcomes, statistical analysis, financial planning, reimbursement, evaluation of quality of care, and communication that supports patient treatment. You will code using current ICD Clinical Modification (CM) and Procedure Coding System (PCS), CPT, and/or HCPCS, and perform comprehensive EHR review and data abstraction to ensure complete and accurate capture. You will also support documentation improvement and provide training and technical guidance to coding staff.

Responsibilities

• Complete accurate diagnostic and procedural coded data for operational, research, reimbursement, and quality use

• Assign codes using ICD-CM/PCS, CPT, and/or HCPCS and apply accepted coding conventions (including appropriate E/M code selection)

• Monitor and apply changing regulatory and policy requirements affecting coded information

• Review electronic health records and abstract medical, surgical, ancillary, demographic, social, and administrative data

• Ensure provider documentation is complete and supports the diagnoses and procedures coded

• Use facility computer systems to code, abstract, record, and transmit data to national VA databases

• Track work status and adjust day-to-day priorities based on established processes

• Instruct and train staff using written instructions, reference materials, and hands-on support

• Analyze documentation systems and recommend improvements to optimize VERA workload and third-party reimbursement

• Identify training needs using productivity/accuracy reports and coding rejects; recommend actions for insufficient performance; identify continuing education needs

• Collaborate with clinicians to improve expectations for medical record documentation

Requirements

• U.S. citizenship

• English proficiency (written and spoken)

• Subject to background/security investigation

• Live within 50 miles of a VA Medical Center

• Eligible for remote/virtual telework; may be required to return to the office

• Pass pre-employment physical examination

• Participate in the seasonal influenza vaccination program

• Meet qualifying experience or education/training requirements in medical terminology/anatomy/physiology and medical coding

• Hold required certification for MRT (Coder) positions (AHIMA or AAPC; or Clinical Documentation Improvement certification where applicable)

• For GS-09: mastery level certification

Benefits

A career with the U.S. government includes a comprehensive benefits package; eligibility depends on the type of position and whether it is full-time or part-time.