Inpatient Medical Coder (Medical Records Technician)

Quick Facts

• Role: Inpatient Medical Coder (Medical Records Technician)

• Focus: Assign inpatient diagnosis and procedure codes for facility MS-DRG and/or professional services

• Schedule: 0600–1800, flexible Monday–Friday

Description

Inpatient Medical Record Technicians (Coders) classify medical data from inpatient records by assigning accurate codes using official coding guidelines. You will abstract and review required clinical, demographic, and administrative information from the electronic health record, resolve coding questions with senior coders/supervisors, and transmit corrected data to the national VA database. The work emphasizes correct ICD/PCS, CPT, and HCPCS coding, documentation quality, and timely completion.

Responsibilities

• Select and assign codes from ICD-10-CM/PCS for inpatient facility MS-DRG coding and/or from CPT/HCPCS for inpatient professional coding

• Apply accepted coding practices, guidelines, conventions, and policy for diagnosis, procedure, and admission coding

• Abstract required data elements from electronic patient records (clinical, surgical, ancillary, demographic, social, administrative)

• Refer provider coding/documentation questions to senior coder or supervisor

• Use facility computer systems and coding/abstracting software to code, record, and transmit data to the national VA database; correct identified errors

• Use office and health record applications (Outlook, Excel, Word, Access) and encoder product suite

• Maintain knowledge of regulatory and policy requirements impacting coded information

• Identify principal diagnosis/procedure for inpatient discharge and determine complications/co-morbidities and CC/MCC and POA indicators for correct DRG/MS-DRG

• Determine admission diagnosis coding upon patient admission

• Link diagnosis to procedure and determine level of service for allowable reimbursement; bundle encounters and identify non-billable encounters

• Orient and instruct new personnel/students on unit operations, coding, abstracting, and electronic health record use

Requirements

• U.S. citizenship

• Written and spoken English proficiency

• Required AHIMA/AAPC (or AHIMA/AcdIS for CDI) certification at the stated apprentice/associate or mastery level

• One year of qualifying experience in medical terminology/anatomy/physiology/pathophysiology and medical coding; or qualifying education in health information technology/health information management; or completion of an approved intensive coding program leading to certification eligibility (with required coursework)

• Selective Service registration (for males born after 12/31/1959)

• Subject to background/security investigation; complete online onboarding and pre-employment requirements

• Pass pre-employment physical evaluation; comply with influenza vaccination requirement

• Complete all application-required documents

Benefits

• Competitive salary with regular salary increases

• Paid Time Off: 37–50 days annually (including annual leave, sick leave, and Federal holidays)

• Parental leave up to 12 weeks paid after 12 months

• Child care subsidy for eligible full-time employees after 60 days

• Traditional federal pension and federal 401K with employer contributions up to 5%

• Comprehensive federal health/vision/dental/term life/long-term care insurance options

• Telework available on an ad-hoc basis; not a virtual position