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    This position is located in the Health Information Management (HIM) section at the VA Central Western Massachusetts Health Care System (VA CWM HCS). 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.

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    Some duties may include:

    • Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services.
    • Selects and assigns codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding.
    • With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
    • Reviews record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
    • Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance.
    • Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed.

    Work Schedule: Monday - Friday 08:00 am - 4:30 pm
    Financial Disclosure Report: Not required

    Travel Required

    Not required

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/600010300. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.