Medical Records Technician (Coder-Outpatient and Inpatient)

Veterans Health Administration • Hines, IL

7d

About The Position

This position is in the Health Information Management section at Edward Hines Jr. VA Hospital. The Medical Records Technician (Coder-Outpatient and Inpatient) classifies medical data from patient health records in hospital and physician-based settings. The role codes inpatient and outpatient encounters across the full range of health care services provided by the facility, using current ICD, CPT, and/or HCPCS coding systems. It requires adherence to coding practices, guidelines, and conventions to support ethical, accurate, and complete coding.

The technician reviews health records and abstracts medical, surgical, ancillary, demographic, social, and administrative data. The role monitors regulatory and policy changes, verifies that provider documentation supports coded diagnoses and procedures, and assists facility staff with documentation and coding-related technical guidance. The position uses facility computer systems and software to code, abstract, record, and transmit data to the national VA database, including VistA, CPRS, encoder applications, Outlook, Excel, Word, and Access. At the supervisor’s direction, the technician may orient and instruct new personnel or students in unit operations, coding, abstracting, and electronic health record use.

Specific duties include coding inpatient and outpatient encounters, identifying inpatient principal diagnoses and procedures and relevant complications or comorbidities for DRG assignment, reviewing and correcting VERA-related codes, coding inpatient professional fee services and operating-room procedures, establishing outpatient diagnoses and procedure codes, updating inpatient and contract nursing home census codes, reviewing and coding Care in the Community encounters, and coding diagnoses from paper forms for VA registries.

The work schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is available. Relocation and recruitment incentives are not authorized.

Requirements

• U.S. citizenship.
• One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format; or qualifying education or an equivalent combination of experience and education.
• Qualifying education may be an associate’s degree in health information technology/health information management or a related degree with at least 12 semester hours in health information technology/health information management; completion of an eligible AHIMA-approved or other intensive coding training program; or an equivalent combination of education and experience.
• A qualifying certification: apprentice/associate-level certification through AHIMA or AAPC; mastery-level certification through AHIMA or AAPC; or clinical documentation improvement certification through AHIMA or ACDIS.
• For GS-8, one year of creditable experience equivalent to the next lower grade level.
• Ability to analyze health records, identify pertinent diagnoses and procedures for coding, and evaluate documentation adequacy, including understanding terminology, findings, and disease processes/pathophysiology.
• Ability to accurately perform the full scope of outpatient coding, including ambulatory surgery, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
• Skill in interpreting and adapting health information guidelines when they are incomplete or insufficiently specific, and in using judgment when completing assignments under those conditions.
• Proficiency in written and spoken English.
• Subject to background/security investigation and pre-employment requirements, including applicable drug screening and seasonal influenza vaccination requirements.
• Must complete the required application and online onboarding processes; selected applicants must provide acceptable identification.
• Must serve a one- or two-year trial period, subject to written certification for continued employment.

Responsibilities

• Assign codes to documented inpatient and outpatient patient-care encounters using current ICD, CPT, and/or HCPCS coding systems.
• Apply accepted coding practices, guidelines, and conventions to select accurate and complete diagnosis, operation, procedure, ancillary, and Evaluation and Management codes.
• Monitor regulatory and policy requirements that affect coded information.
• Review patient health records and abstract medical, surgical, ancillary, demographic, social, and administrative data.
• Assist facility staff with documentation requirements and provide technical support regarding regulations, coding requirements, resident supervision, reimbursement, workload, nomenclature, and sequencing.
• Verify provider documentation is complete and supports coded diagnoses and procedures; locate supporting documentation in the health record.
• Use facility computer systems and software to code, abstract, record, and transmit data to the national VA database.
• Orient and instruct new personnel or students, as directed by the supervisor, on unit operations, coding, abstracting, and electronic health record use.
• Identify the principal diagnosis and principal procedure for inpatient discharges, along with significant complications or comorbidities, to determine the appropriate DRG.
• Re-review codes identified by the VERA committee, correct coding as needed, and ensure VERA coding requirements are followed.
• Code inpatient professional fee services for identified inpatient admissions.
• Establish primary and secondary diagnosis and procedure codes for outpatient encounters, link diagnoses to procedures, and determine the level of Evaluation and Management service provided.
• Code Operating Room procedures reported in the VistA Surgical Package, ensure procedures file to the appropriate PCE, and add Anesthesia and Pathology codes for billable surgical cases.
• Update codes for current inpatient and Contract Nursing Home admissions for quarterly census and requested billable long-stay admissions.
• Review and code assigned fee-service Care in the Community inpatient and outpatient encounters using documentation from non-VA facilities.
• Code diagnoses from paper forms for VA registries.

Benefits

• Federal employee benefits package is available to eligible employees; specific benefits depend on position type and must be confirmed with the hiring agency.
• Eligible selected applicants may request credit for prior federal or military service toward annual leave accrual, subject to approval and not guaranteed.

What This Job Offers

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