Medical Records Technician (Outpatient Coder)

Quick Facts

• Role: Medical Records Technician (Outpatient Coder)
• Schedule: Monday–Friday, 8:00am–4:30pm
• Work setup: Remote work currently authorized; may require return to office if policy changes or exemptions are not extended
• Telework: Not available

Description

Outpatient MRTs (Coders) perform full-scope outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. You will assign and select diagnosis and procedure codes from current ICD, CPT, and HCPCS resources, review records for complete data capture, ensure provider documentation supports coded diagnoses/procedures, and monitor regulatory and policy changes to maintain coding accuracy and compliance.

Responsibilities

• Assign codes to outpatient and/or inpatient professional services encounters covering the full range of healthcare services
• Apply medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to select appropriate codes
• Select and assign codes from current ICD, CPT, and/or HCPCS
• Follow accepted coding practices, guidelines, and conventions for accurate diagnosis/procedure selection and E/M coding
• Monitor ever-changing regulatory and policy requirements affecting coded information
• Perform comprehensive record review and abstraction for medical, surgical, ancillary, demographic, social, and administrative data (paper or electronic)
• Support documentation requirements and provide technical support on coding/documentation, regulations and policy, reimbursement, accepted nomenclature, and proper sequencing
• Ensure provider documentation is complete and supports the diagnoses and procedures coded
• Consult with clinical/professional staff to clarify conflicting or ambiguous clinical data
• Report incorrect documentation or codes in the electronic patient health record

Requirements

• U.S. citizenship (selective eligibility for non-citizens only if VA cannot recruit qualified citizens)
• Proficient in written and spoken English
• Subject to background/security investigation
• Pass pre-employment physical evaluation
• Complete online onboarding and pre-employment requirements, including acceptable identification
• Meet basic education/experience requirements related to medical terminology, anatomy/physiology/pathophysiology, medical coding, and health record structure
• Obtain and maintain required AHIMA/AAPC (or AHIMA ACDIS) certification through continuing education

Benefits

• Competitive salary and regular salary increases
• Paid time off: 37–50 days annually (annual leave, sick leave, and federal holidays)
• Paid parental leave after 12 months (up to 12 weeks)
• Child care subsidy after 60 days for eligible employees
• Federal retirement: traditional pension (5 years vesting) and 401K with up to 5% employer contributions
• Federal insurance: health/vision/dental/term life/long-term care