This position is located in the Health Information Management (HIM) section at the VA Loma Linda Medical Center. 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.
These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.
Medial Record Technicians (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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.
Major Duties include but are not limited to: Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAMC. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients.
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.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; 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.
Consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. 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. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Researches references to resolve any questionable code errors; contacts supervisor as appropriate.
Utilizes a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (Vista and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes.
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. Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
Work Schedule: Monday - Friday 0730 am - 4:00 pm Telework: Virtual: This is not a virtual position. Remote: This is a remote position. (The option for remote work will be assessed continuously, and you may need to return to a VA office if required.) Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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/.
Adam.Paulsen@va.gov · 319- 509-5998
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $36409 – $72644/yr.
Yes, this position is fully remote.
This position requires a Other security clearance.
Applications close on 2026-09-04.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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