This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.

Role Description

The Medical Records Technician (Coder - Outpatient and Inpatient) is located in the Health Information Management (HIM) Service at the Veterans Healthcare System of the Ozarks VA Medical Center.

• Select and assign codes from current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS classification systems to both inpatient and outpatient records.
• Assign codes to documented patient care encounters covering the full range of health care services provided by the VAMC.
• Apply advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures.
• Select and assign codes from the current version of several coding systems.
• Adhere to accepted coding practices, guidelines, and conventions for ethical, accurate, and complete coding.
• Perform a comprehensive review of the patient health record to abstract necessary data.
• Assist facility staff with documentation requirements to accurately reflect patient care.
• Ensure provider documentation supports the diagnoses and procedures coded.
• Consult with professional staff for clarification of conflicting or ambiguous clinical data.
• Utilize the facility computer system and software applications to code, abstract, record, and transmit data.
• Identify the principal diagnosis and principal procedure for every inpatient discharge.
• Code inpatient professional fee services for identified inpatient admissions.
• Establish primary and secondary diagnosis and procedure codes for billable outpatient encounters.

Qualifications

• United States Citizenship.
• Proficiency in spoken and written English.
• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Associate's degree from an accredited college or university in health information technology/management or related field.
• Completion of an AHIMA approved coding program or equivalent intense coding training program.
• Equivalent combinations of creditable experience and education are qualifying.
• Certification through AHIMA or AAPC is required.

Requirements

• Skill in applying current coding classifications to various inpatient and outpatient specialty care areas.
• Ability to communicate with clinical staff regarding coding and documentation issues.
• Ability to research and solve coding and documentation related issues.
• Skill in reviewing and correcting system or processing errors.
• Ability to abstract, assign, and sequence codes accurately.

Benefits

• 37-50 days of annual paid time off per year.
• Up to 12 weeks of paid parental leave after 12 months of employment.
• Childcare subsidy for eligible employees after 60 days of employment.
• Traditional federal pension and federal 401K with up to 5% contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance options.

Work Schedule

Monday - Friday, 7:00am - 3:30pm. Schedule subject to change based on the needs of the service.

Physical Requirements

Physical aspects associated with work required of this assignment are typical for the occupation, including standing, lifting, carrying, sitting, stooping, bending, pulling, and pushing.

Work Environment

Work is performed in an office/clinic setting with minimal risks, requiring normal safety precautions.