Lead Medical Records Technician (Coder)

Lead Medical Records Technicians (Coder) must be able to perform all duties of a Medical Records Technician (Coder). Lead Medical Records Technicians (Coder) review coding and assist Medical Records Technicians (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate prepare and maintain various reports and analyze data; and may also coordinate assign and monitor workflow.

Total Rewards of a Allied Health Professional

Duties include but are not limited to:

• Assigns codes to documented patient care encounters (inpatient and/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
• 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).
• Adhere 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.
• Apply 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.
• Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VA Medical Center (VAMC).
• Perform a comprehensive review of the patient health record to abstract medical surgical ancillary demographic social and administrative data to ensure complete data capture.
• Assist 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.
• Ensure provider documentation is complete and supports the diagnoses and procedures coded.
• Expertly search 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.
• Correct any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.
• Use a variety of computer applications in day-to-day activities and duties such as Outlook Excel Word and Access; competent in use of health record applications (Vista and CPRS) as well as the encoder product suite.
• Ensure current versions of all software applications are loaded and functional after any updates or changes.

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7 2025 drivers licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the Required Documents section of this announcement.

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements:

• United States Citizenship. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).
• Experience and Education:
• Experience. One year of creditable experience that indicates knowledge of medical terminology anatomy physiology pathophysiology medical coding and the structure and format of a health records.

• Education. An associates degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g. courses in medical terminology anatomy and physiology medical coding and introduction to health records);

• Completion of an AHIMA approved coding program or other intense coding training program of approximately one year or more that included courses in anatomy and physiology medical terminology basic ICD diagnostic/procedural and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor or comparable international accrediting authority at the time the program was completed;

• Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
• (a) Six months of creditable experience that indicates knowledge of medical terminology general understanding of medical coding and the health record and one year above high school with a minimum of 6 semester hours of health information technology courses.
• (b) Successful completion of a course for medical technicians hospital corpsmen medical service specialists or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy physiology and health record techniques and procedures. Also requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)

• (1) Apprentice/Associate Level Certification through AHIMA or AAPC
• (2) Mastery Level Certification through AHIMA or AAPC.
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.

• Ability to work with a team to provide technical guidance plan organize and coordinate activities in order to effectively complete job duties of assignment such as distributing workload monitoring the status and progress of work monitoring accuracy of work etc.
• Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient inpatient outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
• Ability to effectively communicate both orally and in writing in order to meet program objectives.
• Knowledge of training methods and the ability to provide training to new coding staff.
• Ability to collect and analyze data and present results in various formats which may include presenting reports to various organizational levels.
• Leadership skills including interpersonal relations and conflict resolution between employees managers and clinical staff.