About the Role
The San Francisco VA Health Care System is seeking a Medical Records Technician (MRT) – Coder to join our Health Information Management (HIM) Section. This position involves abstracting medical record data and assigning accurate codes using ICD, CPT, and HCPCS classification systems for inpatient and professional services. This role ensures precise documentation for patient care, billing, and regulatory compliance.
Note: Remote work is temporary and contingent on a final decision regarding the Return to Office (RTO) exemption. Applicants must reside within 50 miles of a VA facility.
Key Responsibilities
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Review and abstract inpatient medical records to assign ICD-10-CM/PCS, CPT, and HCPCS codes accurately.
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Assign codes for complex medical and specialty cases, including surgical procedures and diagnostic studies.
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Consult clinical staff to clarify conflicting or incomplete documentation.
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Maintain 95% coding accuracy on quality audits and correct audit findings.
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Use encoder software to sequence codes, resolve edits, and ensure compliance with medical necessity standards.
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Monitor regulatory and policy changes affecting coding and apply them to all relevant services.
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Train new personnel or students on coding procedures, HIM operations, and electronic health record (EHR) usage.
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Follow ethical coding practices and guidelines, including VERA program standards.
Required Qualifications
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U.S. Citizenship and proficiency in written and spoken English.
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Education/Experience: One year of experience in medical records, or an associate’s degree in Health Information Technology, HIM, or related field with relevant coursework.
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Certification:
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Apprentice/Associate, Mastery, or Clinical Documentation Improvement certification via AHIMA or AAPC.
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Knowledge & Skills:
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Ability to accurately analyze and code complex inpatient records.
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Strong understanding of health record documentation, disease processes, and coding standards.
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Skill in interpreting incomplete or ambiguous guidelines to complete coding assignments.
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Benefits & Work Environment
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Competitive federal employee benefits, including health, dental, vision, and retirement plans.
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Earn annual leave based on years of federal service.
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Access to professional development opportunities and federal employee resources.
Additional Information
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Temporary remote work available through October 2025. Return to office may be required afterward.
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Must participate in the seasonal influenza vaccination program.
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The position is in the Excepted Service under Title 38 and does not confer competitive status.
Apply Now to join the San Francisco VA Health Care System and support veterans through accurate medical coding and high-quality health information management.