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 section at the Eastern Oklahoma VA Healthcare System. Medical Records Technicians (Coders) classify medical data from patient health records in hospital and physician-based settings. The full performance level is GS-08; selection may be at GS-04 through GS-08.

The role reviews electronic health records and codes inpatient and outpatient care, adhering to accepted coding practices and guidelines, including Veterans Equitable Resource Allocation (VERA) requirements. It monitors regulatory and policy changes affecting coded information, supports complete and accurate data capture, and ensures timely transmission of information to national VA databases.

The position assists facility staff with documentation and coding requirements, consults professional staff to clarify conflicting or ambiguous clinical data, and researches coding questions. Work is scheduled Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is available.

Requirements

• U.S. citizenship; non-citizens may be appointed only when qualified citizens cannot be recruited under VA policy.
• Proficiency in written and spoken English.
• Meet the basic experience or education requirement through one of the following: one year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format; an applicable associate degree with the required health information coursework; completion of an eligible coding training program; or an equivalent combination of experience and education.
• Hold an apprentice/associate or mastery-level certification through AHIMA or AAPC, or a clinical documentation improvement certification through AHIMA or ACDIS.
• For GS-5, have one year of qualifying experience at the next lower grade or the specified bachelor's degree; demonstrate the listed coding, health-record, software, documentation, and workload KSAs.
• For GS-6, have one year of qualifying experience at the next lower grade and demonstrate the listed record analysis, documentation, confidentiality, coding-system, and MS-DRG KSAs.
• For GS-7, have one year of qualifying experience at the next lower grade and demonstrate the listed specialty coding, clinical communication, research, error-correction, sequencing, and MS-DRG KSAs.
• For GS-8, have one year of qualifying experience at the next lower grade and demonstrate the listed full-scope inpatient and outpatient coding, record analysis, and guideline interpretation KSAs.
• Complete the required application steps, including the online assessment, and meet applicable background/security and onboarding requirements.
• Register for Selective Service if required.
• Participate in the seasonal influenza vaccination program as a VA health care personnel requirement.
• Serve a one- or two-year trial period, as applicable.

Responsibilities

• Select appropriate diagnosis, operation, procedure, ancillary, and evaluation and management codes using accepted coding practices, guidelines, and conventions.
• Apply coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program.
• Monitor regulatory and policy requirements affecting coded information and comply with coding changes in a timely manner.
• Review electronic health records and abstract medical, surgical, ancillary, demographic, social, and administrative data for complete data capture.
• Assist facility staff with documentation requirements and provide technical support on regulations, coding, resident supervision, reimbursement, workload, nomenclature, and sequencing.
• Ensure provider documentation supports the diagnoses and procedures coded; 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 to code, abstract, record, and transmit data to national VA databases.
• Correct data errors or inconsistencies promptly to support acceptance in national VA databases within established timelines.
• Research references to resolve questionable code errors and contact a supervisor as appropriate.
• Perform other duties as assigned, depending on grade level.

Benefits

• Federal employee benefits package is available; specific eligibility depends on position type.
• Potential credit toward annual leave accrual may be available for qualifying prior federal or military service, subject to approval.

What This Job Offers

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