Medical Records Technician (Coder-Outpatient and Inpatient)

US Department of Veterans Affairs; Tulsa (OK); Remote; USD 55,000 - 75,000; Full time

Benefits offered by this job

Telework available

Job summary

US Department of Veterans Affairs Eastern Oklahoma VA Health Care System in Tulsa seeks a Medical Coder to ensure accurate assignment of diagnosis and procedure codes and precise data abstraction from the electronic health record (EHR).

The role emphasizes adherence to coding guidelines, VER A program rules, and timely updates to regulatory changes, with telework options and a standard Monday–Friday schedule.

Responsibilities

• Adheres to coding guidelines to assign accurate diagnoses and procedures.
• Complies with VER A program classification and resource-based coding rules.
• Monitors regulatory changes affecting coded data across VA services.
• Reviews electronic health records to abstract medical, surgical, demographic, and administrative data.
• Ensures provider documentation supports codes and coordinates with staff for clarity.
• Uses VA systems to code, abstract, and transmit data to national databases.
• Rectifies data errors to ensure timely national VA database acceptance.
• Performs other duties as assigned; may vary by grade level.

Job description

Job Title

Eastern Oklahoma VA Health Care System - Eastern Oklahoma VA Health Care System Tulsa (James Mountain Inhofe VAMC) Major Duties and Responsibilities:

• 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.
• Adheres to the coding guidelines specific to 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 is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Performs a comprehensive review of the electronic 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.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient record.
• Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases.
• Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
• Independently researches references to resolve any questionable code errors, contacts supervisor as appropriate.
• Perform other duties as assigned depending on grade level.

Work Schedule: Monday - Friday 8:00 to 4:30.

Telework: Available

Functional Statement #: 54175A, 54176A, 54177A, 54178A, 54179A