Medical Records Technicians (MRTs) classify medical data from patient health records in hospital or physician-based settings such as offices, group practices, clinics, and specialty centers. They analyze and abstract patient health records, assigning alphanumeric codes for diagnoses and procedures.
Key duties include:
- Assigning codes to outpatient and inpatient professional services using ICD, CPT, and HCPCS coding systems
- Adhering to coding practices, guidelines, and conventions for accurate, ethical, and complete coding
- Monitoring regulatory and policy changes affecting coding
- Reviewing patient health records (paper or electronic) to abstract comprehensive medical, surgical, ancillary, demographic, social, and administrative data
- Providing technical support on coding regulations, reimbursement, documentation, and policy compliance
- Consulting clinical staff for clarification of ambiguous documentation
- Utilizing facility computer systems (VistA, CPRS, encoder product suite) and software applications (Outlook, Excel, Word, Access) to code and transmit data
- Training new personnel and students on coding operations and electronic health record use
- Conducting coding re-reviews to ensure compliance with VERA program requirements
- Coding inpatient professional fee services and ensuring proper linkage of diagnosis to procedures and E/M service levels
- Applying CPT coding nuances for insurance cost recovery and identifying billable/non-billable encounters
- Coding procedures reported in surgical packages and fee service care in the community
This position is on-site and requires commuting or relocation near West Palm Beach, FL. No telework or virtual work is available.
Work schedule: Monday-Friday, 8:00 AM - 4:30 PM.
Applicants must meet citizenship, education, experience, and certification requirements with proficiency in medical terminology, anatomy, physiology, pathophysiology, and medical coding. Certifications from AHIMA or AAPC are required (Apprentice/Associate, Mastery, or Clinical Documentation Improvement). The position aligns with GS-8 grade level.
- U.S. citizenship required; non-citizens appointable only if no qualified citizens available per VA policy
- Proficiency in spoken and written English per VA standards
- One year of creditable experience or equivalent education in health information technology/management, medical terminology, anatomy, physiology, medical coding, and health records
- Completion of an accredited AHIMA approved coding program or equivalent training leading to coding certification eligibility
- Certification required: Apprentice/Associate or Mastery Level certification through AHIMA or AAPC, or Clinical Documentation Improvement certification through AHIMA or ACDIS
- Knowledge, Skills, and Abilities (KSAs): ability to analyze health records for diagnoses and procedures, perform full scope outpatient and inpatient coding, interpret health information guidelines, use judgment in coding under incomplete guidance
- Experience equivalent to GS-7 level plus demonstrated KSAs to qualify for GS-8 level
- Physical requirements: primarily sedentary work with occasional walking and standing; no special physical effort required
Location
Florida, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$59,515 - $77,366
Remote work allowed
No
Posted
4 months ago