Lead Medical Records Technician (Coder-Inpatient)

Summary

The Inpatient Lead Coder must be able to perform all duties of a MRT (Coder). They serve as a subject matter expert and resource for coding staff and other health care professionals regarding coding guidelines, policies, and regulatory requirements for inpatient health records.

The incumbent is responsible for overseeing the inpatient coding processes, ensuring compliance with Veterans Affairs, federal regulations, and industry standards.

Duties

• Temporarily eligible for Remote work within 50 miles of a VA Medical Center.
• May fall under the Presidential Memorandum tiled “Return to In-Person Work” which will require you to go into the office if the exemption is not approved at the next review.
• Major Duties include, not limited: The Inpatient Lead Coder must be able to perform all duties of a MRT (Coder).
• The incumbent is responsible for overseeing the inpatient coding processes, ensuring compliance with Veterans Affairs, federal regulations, and industry standards.
• Performs and/or reviews the assignment of International Classification of Diseases, Clinical Modification (ICD-10-CM), ICD-10-PCS procedure codes, and Diagnosis Related Groupings (MS-DRGs or APR-DRGs) based on documentation within inpatient medical records.
• Conducts regular internal audits of inpatient coding to ensure accuracy, compliance with regulatory and VA policies, and appropriate reimbursement.
• Collaborates with providers, clinical documentation improvement staff, and other stakeholders to clarify ambiguous documentation, resolve coding discrepancies, and support accurate clinical documentation.
• Provides direction and support to the inpatient coding team, assists in workload distribution, and acts as a coordinator for inpatient coding-related initiatives.
• Orient and instruct new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software.
• Ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection.
• Monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs.
• Develop coding training material and present a curriculum encompassing ongoing training initiatives.
• Provide assistance with coding inquiries from providers, MRTs (Coder), billers, and other facility staff.
• Work Schedule: Monday – Friday, 8:00 a.m. – 4:30 P.M Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.
• The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs).
• Telework: Not applicable, this is a remote position.
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

Requirements

• 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• Effective May 7, 2025, driver’s 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 examination.
• 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.
• As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
• In determining if your employment advances the public interest, we may consider: 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.
• Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

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/.

How You Will Be Evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate’s abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Required Documents

To apply for this position, you must provide a complete Application Package which includes:

• Professional Certification
• Resume Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document.
• This one-page document does not need to be modified and must be uploaded into the two-page restricted ‘Resume’ document upload field.
• Your full resume/CV may be uploaded without page limitation into the ‘Other’ document upload field.
• The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50’s (current/former Federal employees), etc.
• Cover Letter DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) License **Highly Recommend** Write to the Knowledge, Skills, and Abilities (KSAs) on a separate document – KSAs are found under qualification/grade requirements in the announcement.**
• Resume/CV exceeding two-pages Professional Certification
• Resume SF-50/ Notification of Personnel Action Transcript