The Medical Records Technician (Coder-Inpatient/Outpatient) works in the Health Information Management (HIM) section at the Clement J. Zablocki VA Medical Center.
This role classifies medical data from patient health records in hospital and physician-based settings, analyzes and abstracts health records, and assigns alpha-numeric codes for diagnoses and procedures. The position requires expertise in ICD-CM, CPT, and HCPCS coding systems.
Key duties include selecting and assigning codes for inpatient and outpatient facility and professional services, coding complex diseases and procedures, reviewing documentation to support assigned codes, abstracting clinical data, sequencing codes in encoder software, supporting medical necessity, resolving encoder edits, correcting audit findings, and consulting with clinical staff to clarify incomplete or conflicting documentation.
The work schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is available.
Basic requirements
- United States citizenship
- English language proficiency
- Ability to meet physical requirements of the position
- MRT (Coder) certification through AHIMA, AAPC, or a clinical documentation improvement certification through AHIMA or ACDIS
- One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure
- Or completion of an AHIMA-approved coding program or equivalent intensive coding training
- Or an approved education/experience combination
Grade-related qualifications
- GS-4: Meets basic requirements only
- GS-5: One year of creditable experience equivalent to the next lower grade, or a qualifying bachelor's degree in health information management or a related field
- GS-6: One year of experience at the next lower grade plus demonstrated knowledge of documentation review, coding guidelines, confidentiality laws, and CCS/DRG-related concepts
- GS-7: One year of experience at the next lower grade plus skill in applying coding classifications across specialty care areas, resolving coding issues, and sequencing codes accurately
- GS-8: One year of experience at the next lower grade plus ability to perform full-scope inpatient/outpatient coding and evaluate documentation quality
Knowledge and skills
- Knowledge of ICD-CM, ICD-PCS, CPT, and HCPCS
- Ability to abstract pertinent information from health records
- Ability to analyze diagnoses, procedures, and documentation adequacy
- Knowledge of CMS, The Joint Commission, HIPAA, Privacy Act, and FOIA requirements
- Ability to manage priorities and complete work within required timeframes
Location
Indiana, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$36,409 - $72,644
Remote work allowed
Yes
Posted
1 week ago