Medical Records Technician (Coder-Outpatient and Inpatient)

This position is located in the Health Information Management (HIM) section at the Fayetteville NC VA Coastal Health Care System. Medical Records Technicians (Coders) classify medical data from patient health records in hospital and physician-based settings such as offices, group practices, multi-specialty clinics, and specialty centers. They analyze and abstract patients' health records and assign alphanumeric codes for each diagnosis and procedure.

The role requires application of coding classifications across specialty care for outpatient and inpatient services, communicating with clinical staff to resolve coding and documentation issues, researching coding-related problems, and ensuring accuracy and completeness of medical coding data. Duties include coding complex cases, consulting clinical staff for clarifications, using encoder software, and auditing coding data. Work schedule is Monday-Friday, 8:00 a.m. to 4:30 p.m. EST. This is a remote position, though return to office may be required if permanent remote exemption is not granted.

Candidates must have certification through AHIMA or AAPC at Apprentice/Associate or Mastery level, or Clinical Documentation Improvement Certification through AHIMA or ACDIS. Experience includes coding inpatient and outpatient records, reviewing medical documentation, assigning ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes, and supporting medical necessity and DRG assignment.

This position operates at GS-07 (developmental) to GS-08 (journey) grade levels, requiring progressive experience and skills as described in VA qualification standards.