Medical Records Coder (Outpatient and Inpatient)

Quick Facts

• Role: Medical Records Coder (Outpatient and Inpatient)

• Schedule: 7:00 AM–6:00 PM, Monday–Friday

• Telework: Available (not a virtual position)

Description

In this Medical Records Technician (Coder) role, you will review patient documentation and assign accurate ICD-10-CM/ICD-10-PCS and/or CPT/HCPCS codes to support DRGs and medical necessity. You will abstract and sequence diagnoses and procedures, consult clinicians for clarification when documentation is incomplete or ambiguous, and correct encoder rejections to ensure codes reflect services rendered.

Responsibilities

• Select and assign ICD-10-CM and ICD-10-PCS and/or CPT and HCPCS codes for inpatient facility and/or professional services
• Conduct comprehensive reviews of health record documentation to code diagnoses, complications/major complications, comorbidities/major comorbidities, surgeries, and procedures
• Independently abstract clinical data to verify documentation supports the assigned codes
• Code complex inpatient medical/specialty disease processes, patient injuries, and procedures across multiple inpatient settings
• Consult clinical staff to resolve conflicting, incomplete, or ambiguous documentation
• Abstract, assign, and sequence codes in encoder software to achieve correct DRG results and resolve encoder edits
• Ensure provider documentation supports the chosen diagnostic and procedural codes and follows required coding nomenclature
• Enter and correct rejected items and resolve data errors or inconsistencies
• Correct and refile records based on audit findings
• Use computer applications to abstract records, assign codes, and record and transmit coded data

Requirements

• U.S. citizenship
• Selective Service registration (for males born after 12/31/1959)
• Proficiency in written and spoken English
• Subject to background/security investigation
• Complete online onboarding and pre-employment requirements, including acceptable identification
• Seasonal influenza vaccination program participation required
• Meet education/experience thresholds in medical terminology, anatomy, physiology, pathophysiology, and medical coding/health record structure
• Maintain required MRT (Coder) certification through AHIMA/AAPC or CDI certification (or qualify under applicable grandfathering provision)
• Ability to analyze inpatient records for diagnoses and procedures, perform the full inpatient coding scope, and apply coding guidelines using judgment when documentation is incomplete

Benefits

Employees receive a comprehensive federal benefits package. Benefit eligibility depends on the position type and full-time/part-time status.