Medical Records Technician Coder-Outpatient and Inpatient

Department of Veterans Affairs•Detroit, MI

27d•Remote

About The Position

We are seeking motivated and dependable Medical Records Technician (Coder - Outpatient and Inpatient)! This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician based settings

Responsibilities

Select and assign codes from current versions of ICD Clinical Modification, CPT, and HCPCS classification systems to both inpatient and outpatient records.
Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with close guidance from higher level MRTs (Coder).
Select and assign codes from current versions of ICD CM, CPT, and HCPCS classification systems to both inpatient and outpatient records.
Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder).
Select and assign codes from current versions of ICD CM, CPT, and HCPCS classification systems to both inpatient and outpatient records.
Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, and query clinical staff, as appropriate, with limited guidance from higher level MRTs (Coder).
Perform coding on outpatient episodes of care and/or inpatient professional services.
Select and assign codes from current versions of ICD CM, CPT, and HCPCS classification systems.
Review record documentation to abstract all required medical, surgical, ancillary, demographic, social and administrative data, with minimal guidance from higher level MRTs (Coder).
Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
Query clinical staff with documentation requirements to support the coding process.
Perform the full scope of inpatient and outpatient coding duties including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services.
Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation, and management services.
Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
Code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties.
Consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.

Benefits

Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)

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