Clinical Documentation Coder — Inpatient/Outpatient

US-Department-of-Veterans-Affair; Fayetteville (NC); On-site; USD 55,000 - 80,000; Full time

Job summary

US Department of Veterans Affairs in Fayetteville, NC seeks a Medical Records Technician (Coder) to classify and abstract patient records with ICD/PCS/CPT codes. The role supports both outpatient and inpatient coding, ensuring documentation aligns with clinical care and reimbursement guidelines.

Applicants should have an associate degree in health information management or related fields and AHIMA/AAPC certifications or coursework. Experience with health records and coding rules is required.

Qualifications

• One year of creditable experience in medical terminology, anatomy, physiology, medical coding, and health records structure.
• Associate degree with emphasis in health information management or related field.
• Completion of AHIMA or similar coding program leading to certification eligibility.

Responsibilities

• Classify and abstract patient records with alpha-numeric codes for diagnoses and procedures.
• Review documentation to ensure accuracy of severity, mortality risk and resource use.
• Collaborate with clinical staff to improve completeness and specificity of health records.
• Adhere to VA/ accrediting guidelines and coding standards in daily practice.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health records knowledge

Communication with staff

Education

Associate degree in Health Information Technology/Health Information Management

12 semester hours in health information management

AHIMA/AAPC coding program completion

Tools

ICD-10-CM/PCS

CPT coding

HCPCS

Job description

US Department of Veterans Affairs in Fayetteville, NC seeks a Medical Records Technician (Coder) to classify and abstract patient records with ICD/PCS/CPT codes. The role supports both outpatient and inpatient coding, ensuring documentation aligns with clinical care and reimbursement guidelines.

Applicants should have an associate degree in health information management or related fields and AHIMA/AAPC certifications or coursework. Experience with health records and coding rules is required.