Lead Medical Records Technician (Coder)

U.S. Department of Veterans Affairs; Oklahoma City (OK); On-site; USD 61,000 - 80,000; Full time

Job summary

The U.S. Department of Veterans Affairs is seeking a Lead Medical Records Technician (Coder) for the Oklahoma City VA Health Care System. This role involves coding patient encounters, ensuring compliance with coding practices, and training new staff. The position offers a competitive salary and a supportive work environment focused on veterans' care.

Qualifications

• Certification in medical coding required.
• Experience in coding and health services.
• Must be a U.S. citizen and proficient in English.

Responsibilities

• Assign codes to patient care encounters and ensure accurate coding.
• Monitor compliance with coding practices and provide training.
• Assist with documentation requirements and support staff.

Skills

Medical terminology

Anatomy & physiology

Coding expertise

Compliance knowledge

Team collaboration

Education

Certification in medical coding

U.S. citizenship

English proficiency

Job description

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U.S. Department of Veterans Affairs provided pay range

This range is provided by U.S. Department of Veterans Affairs. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$61,111.00/yr - $79,443.00/yr

Summary

The OKLAHOMA CITY OK, Health Administration Service is recruiting for one Lead Medical Records Technician (Coder). This position will be assigned to the Oklahoma City VA Health Care System.

Duties

The Lead Coder provides support to Veterans at the Oklahoma City Veterans Affairs Health Care System (OKCVAHCS). OKCVAHCS is a Level 1b major interdisciplinary teaching facility with service-lines serving medical, surgical, and neurological inpatients and outpatients, with a Level III Emergency Department, and multiple community-based outpatient clinics (CBOC). There is a large outpatient psychiatric population, an Outpatient behavioral health units (Trauma Recovery Services, Substance abuse treatment and Ambulatory Mental Health) and acute gero-psych inpatient as well as a general acute care inpatient psychiatric unit.

Basic Functions

• Assigns codes to documented patient care encounters (inpatient and/or outpatient) covering the full range of health care services provided by the VAMC. Patient encounters are often complicated and complex requiring extensive coding expertise.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Selects and assigns codes from the current version of several coding systems including ICD, CPT, and HCPCS.
• Adheres to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding, including specific guidelines for diagnoses, procedures, and the VERA program.
• Monitors regulatory and policy changes affecting coded information, ensuring compliance and accuracy for all services provided by the VAMC.
• Performs comprehensive review of patient health records to abstract medical, surgical, ancillary, demographic, social, and administrative data for various purposes including profiling, budgeting, reporting, billing, and research.
• Assists facility staff with documentation requirements, providing technical support, ensuring documentation supports coded diagnoses and procedures, and reporting discrepancies.
• Searches patient records to find documentation justifying code assignment, utilizing extensive knowledge of the organization and record structure.
• Uses facility computer systems and software to code, abstract, record, and transmit data to the VA database.
• Trains new personnel and students on unit operations, coding, abstracting, and electronic health records.
• Works within a team environment, supporting peers, managing multiple tasks, and adapting to changing priorities.

Lead Functions

• Monitors work progress and adjusts priorities accordingly.
• Recommends improvements in documentation systems, reviews compliance, and identifies training needs.
• Participates in training and orientation of new staff and students.

Work Schedule

Monday to Friday, 8:00 AM to 4:30 PM

Location

Negotiable location within VA space.

Qualifications

Includes certification requirements, U.S. citizenship, English proficiency, experience, education, and other criteria detailed in the original description. A transcript must be submitted if qualifications are based on education.

Additional Information

Details on service credit, application options, benefits, and other employment conditions are included in the original description.