Summary
This position is located in the Health Information Management section at the Fayetteville NC VA Coastal Health Care System. Medical Records Technicians (Coder) classify medical data from patient health records in hospital and physician-based settings. They analyze and abstract health records and assign alpha-numeric codes for each diagnosis and procedure.
Duties
- Serve as the liaison between health information management and clinical staff
- Improve the quality, completeness, and accuracy of health record documentation through collaboration with clinical, coding, and other staff
- Review documentation and facilitate modifications to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources
- Identify opportunities for documentation improvement and ensure diagnoses and procedures are documented to the highest level of specificity
- Develop and update medical center policy related to clinical documentation improvement
- Review health record content and documentation requirements
- Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation
- Collect, analyze, graph, and report documentation-related data to leadership
- Provide education and training to clinical staff on documentation standards and improvement techniques
- Support inpatient and outpatient documentation review, including admissions, discharges, observation, emergency department, urgent care, and clinic visits
- Ensure documentation supports coding, reimbursement, workload capture, and resource allocation
- Provide technical support related to regulations, policy, coding requirements, resident supervision, reimbursement, workload, and proper sequencing
- Other duties as assigned
Work Schedule
Monday-Friday, 8:00 a.m. to 4:30 p.m.
Other Information
- Telework available
- Not a virtual position
- Sign-on bonus may be authorized for new-to-federal-service applicants only
- Permanent change of station (PCS) not authorized
Requirements & Qualifications
Qualifications
- United States citizenship, with exceptions only as allowed by VA policy
- Proficiency in spoken and written English
- One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records
- Or an associate's degree in health information technology/health information management, or a related degree with at least 12 semester hours in relevant coursework
- Or completion of an AHIMA-approved coding program or equivalent intensive coding training program
- Or an equivalent combination of education and experience
- For GS-09 level, one year of experience equivalent to the GS-08 level, or qualifying education/certification and clinical documentation improvement experience
- Required certifications may include mastery-level AHIMA/AAPC certification or CDI certification such as CDIP or CCDS
- Demonstrated knowledge of coding and documentation concepts, clinical terminology, anatomy and physiology, pathophysiology, pharmacology, regulations, ICD-CM/PCS, CPT, HCPCS, CC/MCC, MS-DRG, and POA indicators
- Ability to analyze data, present results, communicate effectively with providers, and support staff education
- Physical requirements include light lifting, moderate carrying, reaching above shoulder, finger dexterity, standing, hearing, and adequate vision
Location
North Carolina, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$64,453 - $83,794
Remote work allowed
Yes
Posted
1 week ago
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