The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder-Inpatient) position. The Medical Records Technician (Coder-Inpatient) is located in the Health Information Management Services (HIMs) section within Patient Care Administrative Service.
Major duties of the Medical Records Technician (Coder - Inpatient) include, but are not limited to: Reviewing record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). Use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled.
Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. Has basic knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.
Coding systems 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 (E/M) code to ensure ethical, accurate, and complete coding.
Maintains current knowledge of regulatory and policy requirements affecting coded information. Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Insures provider documentation supports the diagnoses and procedures coded. Consults with a more senior coder or the supervisor to resolve issues related to conflicting or questionable clinical documentation.
Uses knowledge of the organization and structure of the patient health record to capture and justify code assignment. Utilizes the facility computer system and software applications to 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 a senior coder or supervisor when needed. Code recurring MDS census for NHCU patients and other special surveys before closeout with knowledge of Prospective Payments Systems such as Resident Assessment Instrument/Minimum Data Set (RAI/MDS), Home Health CMS requirements and Fee Basis Coding.
Uses a variety of computer 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. Identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Codes inpatient professional fee services for identified inpatient admissions.
Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement. Codes less complex Operating Room procedures reported in the Surgical Package of the Vista hospital system.
Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions Work Schedule: Monday- Friday, 8:00am - 4:30pm Remote: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.
Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order. Virtual: This is not a virtual position. Functional Statement #: 91787A, 91788A, 91789A, 91790A, 91791A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): 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/.
heather.moncini-watson@va.gov · 216-392-6627
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $38017 – $75852/yr.
Yes, this position is fully remote.
Applications close on 2026-11-09.
This position is open under the 'Fed Competitive' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-29 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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