Medical Records Technician (Coder-Outpatient and Inpatient)

US Veterans Health Administration; United States; On-site; USD 75,000 - 110,000; Full time

Benefits offered by this job

PTO (Paid Time Off)

Parental leave

Childcare subsidy

Federal retirement

Federal health/vision/dental

Job summary

The Southeast Louisiana Veterans Healthcare System is seeking MRT (Coder) professionals to classify and abstract patient health records, assigning ICD, CPT, and HCPCS codes. You will ensure accurate documentation, support research and reimbursement efforts, and stay compliant with VA coding guidelines and VER A requirements.

Ideal candidates will analyze records from inpatient and outpatient settings, utilize VistA/CPRS and encoder tools, and collaborate with clinical staff to resolve coding

Qualifications

• Expertise in ICD, CPT, and HCPCS coding systems.
• Ability to abstract data from patient health records.
• Knowledge of medical terminology and anatomy.

Responsibilities

• Assign codes to documented patient encounters (inpatient and outpatient).
• Ensure code choices follow coding guidelines and VER A rules.
• Review patient records to capture complete data.
• Use VistA/CPRS and encoder tools for coding and data transmission.
• Maintain timely compliance with regulatory changes.

Skills

Medical coding

ICD expertise

CPT/HCPCS knowledge

Regulatory compliance

Tools

VistA

CPRS

Encoder product suite

Job description

Summary

This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System. 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 centers.

Learn more about this agency

The public

U.S. Citizens, Nationals or those who owe allegiance to the U.S.

Federal employees – Competitive service

Current federal employees whose agencies follow the U.S. Office of Personnel Management’s hiring rules and pay scales.

Federal employees – Excepted service

Current federal employees whose agencies have their own hiring rules, pay scales and evaluation criteria.

Internal to an agency

Current federal employees of the hiring agency that posted the job announcement.

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. HT38 Internal/External: This job is open to current permanent VA Nationwide employees, Federal employees of other Agencies, and U.S. Citizens

Duties

These coding practitioners analyze and abstract patients’ health records, and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation.

Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. Has basic knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.

Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD), 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 (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 patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research 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. Insures 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.

Expertly 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. Independently researches references to resolve any questionable code errors; contacts supervisor as appropriate.

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.

Work Schedule

Monday-Friday; 7am-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 $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

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)

Remote Position

This position currently has a Return to Office (RTO) mid-term extension (180-days). However, candidates may be subject to return to office in the event policy changes or the exemption is not extended.