This position is located in the Health Information Management (HIM) section at the California VA Health Care System (CVAHCS). 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.
Duties may include, but are not limited to: Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise.
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 E/M code to ensure ethical, accurate, and complete coding.
Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic.
The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs.
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.
Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Work Schedule: Monday - Friday 0730 - 1600 Telework: Not Available Virtual: This is not a virtual position. 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
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.
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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