Medical Records Technician (Coder-Outpatient and Inpatient)

Veterans Health Administration • Tulsa, OK

1d • Hybrid

About The Position

This position is in the Health Information Management (HIM) section at the Eastern Oklahoma VA Healthcare System. The Medical Records Technician (Coder) classifies medical data from patient health records in hospital and physician-based settings. The role reviews electronic health records, abstracts relevant clinical and administrative information, and assigns accurate diagnosis, procedure, ancillary, and evaluation and management codes in accordance with accepted coding standards and applicable VA requirements. The position supports accurate facility databases and cost-recovery programs by monitoring regulatory and policy changes and correcting coding or data issues within established timelines.

The role provides technical guidance to facility staff on documentation, coding, regulations and policy, reimbursement, workload, nomenclature, and sequencing. It verifies that provider documentation supports the assigned codes and consults professional staff to clarify conflicting or ambiguous clinical information. The position uses facility computer systems and software to code, abstract, record, and transmit data to national VA databases, and researches questionable coding issues as needed. The full performance level is GS-08; selection may be made at GS-04 through GS-08. The position is based at the Eastern Oklahoma VA Healthcare System in Tulsa, with telework available, and follows a Monday–Friday, 8:00 a.m.–4:30 p.m. schedule.

Requirements

• U.S. citizenship, except that non-citizens may be appointed when qualified citizens cannot be recruited in accordance with VA policy.
• Proficiency in written and spoken English.
• Meet the basic experience or education requirement through one year of creditable experience involving medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format; an applicable associate degree with at least 12 semester hours in health information technology/management; completion of an eligible intensive coding training program of approximately one year or more; or an equivalent combination of experience and education.
• Hold an apprentice/associate-level or mastery-level certification through AHIMA or AAPC, or a Clinical Documentation Improvement certification through AHIMA or ACDIS.
• For GS-5 and above, meet the applicable grade-level experience or education requirements and demonstrate the knowledge, skills, and abilities specified for that grade. GS-5 education may include a bachelor's degree in health information management or a related degree with at least 24 semester hours in health information management or technology.
• Demonstrate ability to use health information technology and office software, navigate and abstract health records, apply coding guidelines and medical terminology, and manage priorities and deadlines, as applicable to grade level.
• For higher grade levels, demonstrate applicable ability to analyze records and documentation, apply confidentiality laws and coding classifications, communicate with clinical staff, research and resolve coding issues, correct system errors, and code inpatient and outpatient cases, including CC/MCC and POA indicators, as applicable to grade level.
• Complete all application requirements, including the online assessment and required onboarding steps.
• Meet background and security investigation requirements and complete required pre-employment identification requirements.
• Register with Selective Service if male and born after December 31, 1959.
• Participate in the seasonal influenza vaccination program as required for VA Health Care Personnel.
• Serve a one- or two-year trial period, during which continued employment is evaluated.

Responsibilities

• Apply accepted coding practices, guidelines, and conventions to select appropriate diagnosis, operation, procedure, ancillary, and evaluation and management codes.
• Follow Veterans Equitable Resource Allocation (VERA) coding guidelines.
• Monitor regulatory and policy requirements affecting coded information and incorporate coding changes in a timely manner.
• Review electronic health records and abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Assist facility staff with documentation requirements and provide technical support on regulations, policy, coding, resident supervision, reimbursement, workload, nomenclature, and sequencing.
• Ensure provider documentation is complete and supports coded diagnoses and procedures.
• Consult professional staff to clarify conflicting or ambiguous clinical data.
• Report incorrect documentation or codes in the electronic patient record.
• Use facility computer systems and software applications to code, abstract, record, and transmit data to national VA databases.
• Correct data errors or inconsistencies promptly to ensure acceptance in the national VA database within established timelines.
• Research references to resolve questionable coding errors and contact a supervisor as appropriate.
• Perform other duties as assigned depending on grade level.

Benefits

• Federal employees and their families have access to a comprehensive benefits package; specific eligibility depends on position type. Selected applicants may be eligible to receive credit toward annual leave accrual for prior work or military service, subject to approval.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree