Medical Records Technician (Coder-Outpatient and Inpatient)

Overview:

The Eastern Oklahoma VA Healthcare System is seeking skilled Medical Records Technicians (Coder) to accurately classify and code medical data from inpatient and outpatient patient health records. This position supports the Health Information Management (HIM) department by ensuring precise and compliant coding based on current standards and guidelines.

Key Duties and Responsibilities:

• Assign codes to patient care encounters using ICD-CM, ICD-PCS, CPT, and HCPCS coding systems.

• Adhere to accepted coding guidelines and conventions, including Veterans Equitable Resource Allocation (VERA) coding rules.

• Review and abstract required data from paper and electronic health records, ensuring documentation supports coding decisions.

• Monitor and implement updates to regulatory and policy requirements related to coding accuracy and compliance.

• Assist facility staff with documentation improvements to support accurate coding and reimbursement.

• Utilize facility computer systems and software (including VistA, CPRS, and encoder tools) to code, abstract, record, and transmit data.

• Identify principal diagnoses, procedures, complications, and co-morbidities to assign appropriate Diagnosis Related Groups (DRGs).

• Code inpatient professional fee services, operating room procedures, anesthesia, and pathology for billable surgical cases.

• Update inpatient and nursing home census codes for billing purposes.

• Support orientation and training of new personnel and students, as directed by the supervisor.

• Perform other related duties as assigned.

Requirements:

Basic Eligibility:

• U.S. Citizenship required.

• Proficiency in written and spoken English.

• Ability to pass a background/security investigation and pre-employment physical.

• Compliance with selective service registration (if applicable).

• Participation in the seasonal influenza vaccination program.

Education and Experience:
Candidates must meet one of the following:

• One year of experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records; OR

• Associate’s degree in health information technology/management or related field with required coursework; OR

• Completion of an AHIMA-approved coding program or equivalent training leading to coding certification eligibility; OR

• Equivalent combination of education and experience.

Certification:
Must hold or obtain one of the following:

• Apprentice/Associate Level Certification (AHIMA or AAPC)

• Mastery Level Certification (AHIMA or AAPC)

• Clinical Documentation Improvement Certification (AHIMA or ACDIS)

Grade Levels:

• GS-4: Meets basic requirements; no additional experience needed.

• GS-5: One year of experience or a bachelor’s degree with relevant coursework; demonstrated skills in health information technology, coding guidelines, and medical terminology.

• GS-6: One year experience at GS-5 level; advanced knowledge of coding classifications and regulatory requirements.

• GS-7: One year experience at GS-6 level; ability to communicate with clinical staff and resolve documentation issues.

• GS-8: One year experience at GS-7 level; performs full scope outpatient and inpatient coding, interprets complex guidelines, and uses judgment with incomplete documentation.

Additional Information:

• Telework available but candidates must reside within 50 miles of Tulsa or Muskogee facilities.

• Selected applicants may receive credit for prior federal or military service in annual leave accrual.

• This position may be subject to the VA’s Return to Office policy based on Presidential Memorandum guidelines.