This position is located within the Health Information Management section at the Fayetteville NC VA Coastal Health Care System. Medical Records Technicians (Coder) analyze and abstract patients' health records from hospital and physician-based settings, assigning alpha-numeric codes for diagnoses and procedures.
Key duties include: performing all duties of a Medical Records Technician (Coder) for inpatient and outpatient settings; serving as a liaison between health information management and clinical staff to improve the overall quality, completeness, and accuracy of clinical documentation; reviewing and facilitating modifications to medical records to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources are documented; identifying opportunities for documentation improvement; developing or updating medical center policies related to clinical documentation; providing extensive clinical staff education; querying clinical staff to clarify documentation; reviewing documentation according to accrediting agencies' guidelines and regulations; and providing technical expertise in coding and documentation requirements.
This role requires extensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, coding guidelines (ICD, CPT, HCPCS), complication/comorbidity coding, MS-DRG structure, and evaluation and management criteria to ensure correct code selection.
Work schedule is Monday to Friday, 8:00 a.m. to 4:30 p.m. This is an onsite position with telework potentially authorized on an ad-hoc basis but no full remote work.
Candidates may be required to travel up to 25% of the time.
The position is part of the federal government, GS-9 pay scale, and includes a comprehensive federal benefits package.
Salary range: $64,453 - $83,794 per year.
Location: Fayetteville, North Carolina (US)
- Must be a U.S. Citizen.
- Selective Service Registration required for males born after 12/31/1959.
- Proficient in spoken and written English.
- Subject to background/security investigation.
- Must complete online onboarding and provide acceptable identification.
- Participation in seasonal influenza vaccination program is required.
Basic Qualifications:
- One year of healthcare experience involving knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records structure.
- OR an associate's degree in health information technology/management or related field with minimum relevant coursework.
- OR completion of an AHIMA approved coding program or comparable accredited intense coding training.
- OR equivalent combinations of education and experience.
Preferred Experience:
- Extensive knowledge of coding rules and regulations including ICD, CPT, HCPCS coding systems.
- Knowledge of CC/MCC, MS-DRG structure, POA indicators.
- Ability to perform clinical documentation improvement duties.
- Certifications such as Certified Coding Specialist (CCS), RHIT, Certified Professional Coder (CPC), Clinical Documentation Improvement Practitioner (CDIP), or Certified Clinical Documentation Specialist (CCDS) are preferred.
Demonstrated skills including knowledge of anatomy/physiology/pathophysiology, strong communication skills, ability to analyze data, knowledge of healthcare regulations and documentation requirements.
Physical Requirements:
- Light lifting under 15 lbs, moderate carrying 15-44 lbs
- Standing 4-6 hours per day
- Extensive use of keyboarding, hearing, and adequate vision.
Comprehensive federal benefits package including competitive salary, predictable schedule, access to innovative technology, modern facilities, annual leave accrual based on federal service, and participation in government health programs.
Additional benefits information available through the U.S. government employment resources.
Location
North Carolina, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$64,453 - $83,794
Remote work allowed
No
Posted
2 weeks ago