Medical Records Technician (Coder Outpatient )

US Department of Veterans Affairs; United States; Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Paid time off

Parental leave

Federal health insurance

Telework

Job summary

US Department of Veterans Affairs is seeking an Allied Health Professional to assign and review codes for both outpatient and inpatient encounters. You will ensure precise code selection using ICD, CPT, and HCPCS conventions, and you will abstract data from patient records to support VA databases.

You will work with VA systems (VistA/CPRS, encoder tools) and collaborate with facility staff on documentation, compliance, and reimbursement workflows.

Qualifications

• Expertise in assigning codes using ICD, CPT and HCPCS conventions.
• Ensure documentation supports diagnoses and procedures and complies with regulations.
• Abstract data from patient records for accurate VA databases.

Responsibilities

• Assign codes for outpatient and inpatient encounters.
• Review and abstract data from patient records for VA reporting.
• Provide guidance on documentation and encoding requirements to staff.
• Ensure correct sequencing and reimbursement opportunities.
• Use VistA/CPRS and encoder tools to code and transmit data.

Skills

ICD CPT HCPCS

Regulatory compliance

Medical coding

Data abstraction

Tools

VistA CPRS

Encoder suite

Outlook

Excel

Word

Access

Job description

Allied Health Professional

Major Duties May Include But Not Limited To:

Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC.

Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.

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 versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.

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.

Ensures provider documentation is complete and supports the diagnoses and procedures coded.

Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.

Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications(VistA and CPRS) as well as the encoder product suite.

Conducts re-reviews of codes abstracted for outpatient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.

Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.

Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.

Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.

Reviews and codes assigned fee service Care in the Community outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.

Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

Work Schedule: Monday - Friday, 7:00am-3:30pm.

Pay: Competitive salary and regular salary increases.

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).

Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $1

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.

Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).

Telework: Remote 100% Outside of Area. This is not a virtual position.

Functional Statement #: 62350F, 62353F, 62355F, 62356F, 62357F