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Lead Medical Records Technician (Coder-Inpatient/Outpatient)

Veterans Health Administration · Department of Veterans Affairs
📍 Anywhere in the U.S. (remote job) 💰 $61722 – $80243/yr 🏠 Remote

Quick Facts

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Job Summary

This position is in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center located in Milwaukee, Wisconsin. MRTs (Coder) 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.

Key Responsibilities

This position is located in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Major Duties: Advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (CD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded. Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.

Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access.

Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. Work Schedule: Monday - Friday 8:00am - 4:30pm Compressed/Flexible: No available Telework: Yes Functional Statement #: 10480F 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/.

Contact

Shenetra.Chatman@va.gov · 912-408-2900 X2721

Frequently Asked Questions

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 security clearance is required?

This position requires a Other security clearance.

What is the application deadline?

Applications close on 2026-10-30.

How many openings are available?

There are 2 openings for this position.

Who is eligible to apply?

This position is open under the 'Fed Internal Search' hiring path.

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