Medical Records Technician (Inpatient Coder)

US Department of Veterans Affairs; United States; Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Paid time off

Parental leave

Federal pension plan

Job summary

US Department of Veterans Affairs is seeking a Health Information Management (HIM) Section MRT (Coder) to classify and abstract patient health records in hospital or physician settings. You will apply ICD, CPT and HCPCS coding with a strong focus on accuracy and regulatory compliance.

The role involves coding complex encounters, aligning with VER A classifications, and providing education on coding and documentation.

Qualifications

• Proficient in ICD, CPT and HCPCS coding for diagnoses and procedures.
• Knowledge of VER A program classifications and guidelines.
• Ability to support documentation requirements and coding compliance.

Responsibilities

• Code diagnoses and procedures for inpatient and professional services.
• Select and assign codes from ICD, CPT, HCPCS based on documentation.
• Ensure codes support proper sequencing, billing and reporting.
• Review provider notes and query for clarification when needed.
• Utilize EHR and encoder tools for coding and documentation.

Skills

ICD CPT HCPCS knowledge

Medical terminology

Anatomy & physiology

E/M coding

Tools

Encoder product suite

Electronic health record systems

Microsoft Outlook

Excel

Word

Teams

Job description

Health Information Management (HIM) Section MRT (Coder)

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. 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.

Duties include but are not limited to:

• Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.
• Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS.
• Assigns codes to documented patient care encounters (inpatient facility and/or professional services) covering the full range of health care services provided by the VAMC.
• Patient encounters are often complicated and complex requiring extensive coding expertise.
• 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.
• 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 codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• 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 health record.
• Uses a variety of computer applications in day-to-day activities and duties, such as Microsoft Outlook, Excel, Word, and Teams; competent in use of electronic health record applications as well as the encoder product suite.

Work Schedule: Monday - Friday 8am - 4:30pm

Recruitment Incentive (Sign-on Bonus): Not Authorized

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) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.

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)

Virtual: This is a virtual/remote position.

Permanent Change of Station (PCS): Not Authorized