Medical Records Technician (Coder-Outpatient)

Veterans Health Administration • Versailles, KY

13h • Hybrid

About The Position

This position is in the Health Information Management (HIM) section of Patient Business Services (PBS) at the Columbus VA Ambulatory Care Center. The Medical Records Technician (Coder-Outpatient) classifies medical data from patient health records in hospital, physician-office, group-practice, multi-specialty clinic, and specialty-center settings. The technician analyzes and abstracts patient health records and assigns alphanumeric codes for diagnoses and procedures. Outpatient coders select and assign codes to outpatient episodes of care and/or inpatient professional services using current versions of ICD-10-CM, CPT, and HCPCS classification systems.

The position uses facility computer systems and software to code, abstract, record, and transmit data; corrects data errors or inconsistencies promptly; and helps ensure data is accepted in the national VA database within established timelines. The technician reviews records comprehensively to capture medical, surgical, ancillary, demographic, social, and administrative data, and assists facility staff with documentation requirements and technical guidance on regulations, coding, resident supervision, reimbursement, workload, nomenclature, and sequencing.

The role requires adherence to accepted coding practices, guidelines, and conventions, as well as monitoring changing regulatory and policy requirements affecting coded information. The technician works within a team, supports peers in meeting goals and deadlines, manages multiple tasks and changing priorities, and works under pressure.

The work schedule is Monday through Friday, 7:30 a.m. to 4:00 p.m. Telework is available for regular teleworkers for six or more days per pay period; this is not a virtual position. The work is sedentary, generally performed seated, with occasional walking, standing, bending, carrying light items, or driving. No special physical demands are required. The full-performance level is GS-08; selection may be at GS-04 through GS-08.

Requirements

• U.S. citizenship is required, subject to the stated VA exception for recruiting qualified citizens.
• Proficiency in spoken and written English.
• Meet the basic experience and education requirements through one of the stated pathways: one year of qualifying experience; a qualifying associate degree; completion of an eligible coding training program; or an allowed combination of education and experience.
• Hold an Apprentice/Associate or Mastery Level certification through AHIMA or AAPC, or a Clinical Documentation Improvement certification through AHIMA or ACDIS, unless covered by the applicable grandfathering provision.
• For GS-5 through GS-8, meet the grade-specific experience or education requirements and demonstrate the listed knowledge, skills, and abilities for the grade.
• Knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format, as applicable to the qualifying pathway and grade.
• Ability to use health information technology and coding software, navigate and abstract health records, and apply relevant coding classifications and guidelines.
• Ability to manage priorities, meet required timeframes, follow up on pending issues, and communicate or resolve coding and documentation questions, as applicable to the grade.
• Apply confidentiality laws and regulations governing health information, including the Privacy Act, Freedom of Information Act, and HIPAA, as required at the applicable grade.
• Complete background/security investigation and online onboarding requirements, and participate in the seasonal influenza vaccination program.
• Serve a one- or two-year trial period, during which continued employment is evaluated.
• Provide required application documents and acceptable identification for pre-employment requirements.

Responsibilities

• Analyze and abstract patient health records and assign alphanumeric diagnosis and procedure codes.
• Select and assign codes to outpatient episodes of care and/or inpatient professional services using current ICD-10-CM, CPT, and HCPCS classification systems.
• Use facility computer systems and software applications to code, abstract, record, and transmit data.
• Correct identified data errors or inconsistencies in a timely manner to support acceptance in the national VA database within established timelines.
• Apply accepted coding practices, guidelines, and conventions to select appropriate diagnosis, operation, procedure, ancillary, or evaluation and management codes accurately and ethically.
• Monitor regulatory and policy requirements affecting coded information and comply with coding changes in a timely manner.
• Conduct comprehensive reviews of patient health records to capture medical, surgical, ancillary, demographic, social, and administrative data.
• Assist facility staff with documentation requirements so records accurately and completely reflect care provided.
• Provide technical support regarding regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Work collaboratively with peers to meet goals and deadlines while managing multiple tasks and changing projects and deadlines.
• Analyze documentation and coding issues, communicate with clinical staff, research and resolve issues, and review and correct system or processing errors as applicable to the grade level.

Benefits

• Federal employees and their families have access to a comprehensive federal benefits package; specific benefit eligibility depends on position type.
• Prior federal or military service may be considered for annual-leave accrual credit, subject to request and approval before appointment.

What This Job Offers

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