Medical Records Technician (Outpatient Medical Coder)

Quick Facts

Medical Records Technician (Outpatient Medical Coder) focused on outpatient coding and health record abstraction.

Description

Perform full-scope outpatient coding for encounters including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters (and/or inpatient professional services). Assign accurate codes using current ICD, CPT, and HCPCS standards, ensure documentation supports diagnoses and procedures, and monitor regulatory and policy updates that affect coding accuracy. Abstract and review paper or electronic health records to capture medical, surgical, ancillary, demographic, social, and administrative data for billing, reporting, and research.

Responsibilities

• Assign codes to documented patient care encounters for the full range of services provided
• Apply medical terminology, anatomy/physiology, disease processes, treatments, diagnostic tests, medications, and procedures to select appropriate codes
• Select and assign codes from current ICD, CPT, and/or HCPCS versions
• Follow accepted coding practices, guidelines, and conventions for accurate and complete code selection (including E/M coding)
• Monitor changing regulatory and policy requirements and ensure timely compliance with coding updates
• Review patient records and abstract medical, surgical, ancillary, demographic, social, and administrative data
• Support documentation requirements to accurately reflect patient care
• Provide technical support on regulations, policy, coding requirements, reimbursement, accepted nomenclature, and proper sequencing
• Ensure provider documentation is complete and supports coded diagnoses and procedures
• Consult clinicians to clarify conflicting or ambiguous clinical data
• Report incorrect documentation or codes in the electronic patient health record
• Perform other duties as assigned

Requirements

• U.S. citizenship; selective service registration for eligible males
• Proficient written and spoken English
• Subject to background/security investigation; complete onboarding and pre-employment requirements (including I-9)
• Pass pre-employment physical evaluation
• Seasonal influenza vaccination requirement
• Basic qualifications within the required timeframe: qualifying experience or qualifying health information technology/health information management education/training (or an approved equivalent combination)
• Maintain required coding/clinical documentation improvement credential (AHIMA/AAPC or CDIS as specified)

Benefits

• Competitive salary and regular salary increases
• Paid time off: 37–50 days annual paid time off per year (annual leave, sick leave, and federal holidays)
• Parental leave after 12 months of employment
• Childcare subsidy after 60 days for eligible full-time employees
• Federal retirement: traditional pension and 401K (up to 5% contributions)
• Federal insurance options including health, vision, dental, term life, and long-term care