Med Rec Tech (Med Coder)

US Department of Veterans Affairs; United States; On-site; USD 55,000 - 75,000; Full time

Job summary

The U.S. Department of Veterans Affairs is seeking a Medial Coding Specialist to assign accurate ICD-10-CM/ICD-10-PCS, CPT, and HCPCS codes. You will review clinical documentation, ensure proper code selection, and support quality reporting across inpatient and outpatient settings.

The role requires familiarity with coding guidelines, regulatory standards, and data accuracy. Proficiency with Excel, Outlook, Word and Teams is essential to collaborate with clinicians and coders.

Qualifications

• Knowledge of ICD-10-CM/ICD-10-PCS, CPT and HCPCS coding guidelines.
• Ability to follow coding guidelines and regulatory policies.
• Experience supporting coding accuracy, audits and data quality.

Responsibilities

• Code diagnoses and procedures using ICD-10-CM/ICD-10-PCS, CPT and HCPCS.
• Ensure proper code selection and ethical coding practices.
• Audit coding accuracy, provide guidance to staff, and support documentation improvement.
• Utilize Outlook, Excel, Word and Teams to manage work and communicate with staff.
• Review and report on coding performance and outcomes for various care settings.

Skills

Medical terminology

Anatomy & physiology

Code selection

Regulatory compliance

Documentation review

Tools

Excel

Outlook

Word

Teams

EHR systems

Encoder suite

Job description

Job Title

Duties

Duties include but not limited to:

• Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment. Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), Current Procedural Terminology (CT), and/or Healthcare Common Procedure Coding System (HCPCS). NOTE: Coders will follow current published ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, CPT Guidelines, as well as other established industry standard coding guidance such as the American Medical Association (AMA) CPT Assistant and the American Hospital Association's (AHA) Coding Clinic.
• Applies comprehensive 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.
• Reviews assigned codes from the current version of several coding systems to include current versions of ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines and conventions when validating the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. Applies guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes 1s crucial to the accuracy of the facility database as well as all cost recovery programs.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
• Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Teams; competent in use of electronic health record applications as well as the encoder product suite.
• Reviews, analyzes and reports performance monitors for inpatient, outpatient, VERA and Non-VA Medical Care (purchased care) coding.
• Audits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records. Audits accuracy and completeness of assigned of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment.
• Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyzes data.
• Facilitates improved overall quality, completeness, and accuracy of coded data. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
• Responsible for performing audits of coded data, developing criteria, collecting data, graphing, trending, and analyzing results, creating reports, and communicating in writing and/or in person to appropriate leadership and groups.

Work Schedule: Monday-Friday 8:00am-4:30pm. Work hours are subject to change based on agency needs.

Virtual: 100%

Functional Statement # 60074F

Relocation/Recruitment Incentives: No

Permanent Change of Station (PCS): Not Authorized

Financial Disclosure Report: Not required