Medical Record Technicians (Coders) classify medical data from patient health records in hospital and physician-based settings. This role focuses on assigning codes for routine inpatient facility and professional services using ICD-10-CM/PCS, CPT, and HCPCS guidelines.
Duties include reviewing documentation, abstracting required data, determining principal diagnoses and procedures, assigning CC/MCC and POA indicators when applicable, supporting reimbursement and DRG accuracy, and working with electronic health record and encoder systems. The position also involves communicating with providers and senior coders to resolve coding questions, correcting system errors, and supporting orientation or training of new staff and students as directed.
Work schedule is Monday-Friday, 0600-1800 (flexible). Telework is available on an ad hoc basis, but this is not a fully virtual position.
Basic requirements
- United States citizenship required, with limited exceptions per VA policy
- Proficiency in spoken and written English
- One of the following certifications:
- Apprentice/Associate Level Certification through AHIMA or AAPC
- Mastery Level Certification through AHIMA or AAPC
- Clinical Documentation Improvement Certification through AHIMA or ACDIS
- One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records, or an associate degree in Health Information Technology/Health Information Management, or completion of an AHIMA-approved coding program, or an equivalent education/experience combination
Grade-based qualifications
- GS-4: Meets basic requirements
- GS-5: One year of experience equivalent to the next lower grade level, or a bachelor's degree in health information management/technology with required coursework
- GS-6: One year of experience equivalent to the next lower grade level plus demonstrated knowledge, skills, and abilities
- GS-7: One year of experience equivalent to the next lower grade level plus advanced coding knowledge and demonstrated abilities
Knowledge and skills
- Ability to use health information technology, EHRs, and coding/abstracting software
- Ability to abstract pertinent information from health records
- Knowledge of ICD-CM/PCS Official Conventions and Guidelines for Coding and Reporting
- Ability to apply medical terminology, anatomy/physiology, and disease process knowledge to code inpatient records accurately
- Knowledge of The Joint Commission, CMS, and health record documentation guidelines
- Ability to analyze records for diagnoses, procedures, and documentation adequacy
- Knowledge of HIPAA, Privacy Act, and FOIA confidentiality requirements
- Knowledge of CPT, HCPCS, CC/MCC, POA indicators, and MS-DRG assignment
- Ability to communicate with clinical staff and research coding/documentation issues
Benefits and perks
- Competitive salary and regular salary increases
- Paid time off: 37-50 days annually, including annual leave, sick leave, and federal holidays
- Potential leave accrual credit for prior work or military service
- Up to 12 weeks of paid parental leave after 12 months of employment
- Child care subsidy eligibility for qualifying employees
- Traditional federal pension and federal 401(k) with up to 5% VA contributions
- Federal health, vision, dental, term life, and long-term care insurance options
Location
Lexington, Kentucky, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$38,163 - $76,144
Remote work allowed
Yes
Posted
1 month ago