MEDICAL RECORDS TECHNICIAN (CODER) OUTPATIENT

U.S. Department of Veterans Affairs; Durham (NC); On-site; USD 40,000 - 60,000; Full time

Job summary

The U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coder) for the Durham VA Healthcare System. This role involves classifying medical data from patient health records, requiring strong knowledge in medical terminology and coding practices. Candidates should have relevant experience or education, with opportunities for advancement up to GS-8 level.

Qualifications

• One year of experience in medical coding and health records.
• Associate's degree or equivalent coding training required.
• Proficiency in spoken and written English is mandatory.

Responsibilities

• Classifying medical data from patient health records.
• Analyzing and abstracting health records for coding.
• Performing outpatient and inpatient coding tasks.

Skills

Medical terminology

Anatomy

Physiology

Pathophysiology

Medical coding

Health records structure

Education

Associate's degree in health information technology/management

AHIMA-approved coding program

Job description

This position is in the Health Information Management (HIM) section at the Durham VA Healthcare System. MRTs (Coder) are skilled in classifying medical data from patient health records in hospital and physician-based settings, such as offices, group practices, clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alphanumeric codes for diagnoses and procedures.

Duties

GS-6 Duties include but are not limited to:

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be tentatively selected but cannot be hired until all requirements are met.

Basic Requirements:

• a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when qualified citizens are unavailable, per chapter 3, section A, paragraph 3g.)
• b. Experience and Education:
  • (1) Experience. One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records structure and format.
  • OR,
  • (2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education, with a major in health information technology/management or a related degree with at least 12 semester hours in relevant courses.
  • OR,
  • (3) Completion of an AHIMA-approved coding program or similar intensive coding training of about one year, leading to eligibility for certification.
  • OR,
  • (4) Experience/Education Combination. Equivalent combinations are qualifying, such as six months of experience plus health information courses, or military training in medical records, with additional experience.

Grade Determinations

GS-6: One year of creditable experience equivalent to GS-5. Duties include outpatient and inpatient coding, record review, data abstraction, and use of computer applications.

GS-7: One year of experience equivalent to GS-6. Duties involve more complex coding with limited guidance, including outpatient and inpatient services, documentation review, and data abstraction.

GS-8: One year of experience equivalent to GS-7. Responsibilities include performing coding with minimal supervision, reviewing clinical data for accuracy, and ensuring proper documentation to support codes.

Additional Information

May qualify under the Grandfathering Provision if applicable. The full performance level is GS-8, and the appointment may be made at grades GS-6 to GS-8.

Physical Requirements: Refer to VA Directive and Handbook 5019.

English Language Proficiency: Proficiency in spoken and written English is required by 38 U.S.C. § 7403(f).