Medical Records Technician (Coder-Outpatient and Inpatient)

Veterans Health Administration; Montgomery (AL); Hybrid; USD 36,000 - 73,000; Full time

Benefits offered by this job

Telework available

Job summary

Veterans Health Administration, part of the Department of Veterans Affairs, is recruiting a Medical Records Technician (Coder-Outpatient and Inpatient). The role focuses on coding clinical data across outpatient and inpatient settings, applying ICD/CPT/HCPCS codes, and ensuring adherence to official coding guidelines.

Located in the Central Alabama Veterans Health Care System (CAVHCS), the position supports health information management with potential telework options.

Qualifications

• Knowledge of medical data classification and coding practices.
• Familiarity with ICD-10-CM/PCS, CPT, HCPCS and E/M coding guidelines.

Responsibilities

• Apply medical coding knowledge to outpatient and inpatient services.
• Select codes from ICD, CPT, HCPCS per guidelines and policy.
• Assign primary and secondary diagnosis and procedure codes.
• Ensure coding accuracy and compliance with VA guidelines.

Skills

Medical coding

ICD/CPT/HCPCS

Medical terminology

VA coding guidelines

Tools

VistA system

encoder software

Job description

Medical Records Technician (Coder-Outpatient and Inpatient)

• Department: Department of Veterans Affairs

This position is located in the Health Information Management (HIM) section at the Central Alabama Veterans Health Care System (CAVHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty center.

Key Responsibilities

Total Rewards of a Allied Health Professional Major duties may include, but are not limited to: Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services.

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). With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.

Assigns codes to documented patient care encounters (outpatient professional services); encounters are routine and less complex or for only one specialty or subspecialty. Selects and assigns codes from the current version of the International Classification of Diseases (ICD) Clinical Modification (CM), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

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. Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation. 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 is crucial to the accuracy of the facility database as well as all cost recovery programs. 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.

Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters. HCPCS codes are used per guidelines.

Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and 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.

Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Work Schedule: Monday - Friday, 8:00am - 4:30pm Telework: Available Virtual: This is not a virtual position. Functional Statement #: 62247F, 62242F, 62241F, 62182F, and 62181F Relocation/Recruitment Incentives: Not Authorized, Permanent Change of Station (PCS): Not Authorized

Requirements & Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.

For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $36409 – $72644/yr.

Is this position remote or telework eligible?

This position is eligible for telework.

What is the application deadline?

Applications close on 2026-10-16.

Who is eligible to apply?

This position is open under the 'Public' hiring path.