Medical Records Coder (Inpatient/Outpatient)

Quick Facts

• Role: Medical Records Technician (Coder) – Inpatient/Outpatient

• Schedule: Monday–Friday, 8:00am–4:30pm

• Telework: Available

Description

The Medical Records Technician (Coder) classifies medical data in inpatient and outpatient settings by abstracting and assigning alpha-numeric codes for diagnoses and procedures. The role requires expertise with ICD and CPT/HCPCS classification systems, ensuring codes accurately reflect documentation and support correct DRG/MS-DRG assignment. Work includes using encoder software, reviewing documentation adequacy, and resolving coding/encoder edits.

Responsibilities

• Select and assign codes from current ICD-CM, ICD-PCS, CPT, and HCPCS for inpatient/outpatient facility and/or professional services

• Code complex diagnoses, injuries, and procedures across specialties

• Abstract and review clinical documentation to ensure diagnoses/procedures are adequately supported

• Assign ICD, CPT, and HCPCS codes and sequence codes to obtain correct DRG and support medical necessity

• Abstract, assign, and sequence codes (including CC/MCC and POA indicators) for correct MS-DRG

• Enter codes into encoder software to resolve encoder edits and ensure accuracy of services rendered

• Correct and refile documentation after audit findings

• Use computer applications to abstract, code, record, and transmit data

• Consult with clinical staff to clarify conflicting, incomplete, or ambiguous documentation

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 required onboarding and pre-employment steps, including acceptable identification

• Pass a pre-employment physical evaluation

• Participate in the seasonal influenza vaccination program

• Meet basic education/experience requirements in medical terminology, anatomy/physiology/pathophysiology, and medical coding (or complete an AHIMA-approved/qualified coding program leading to certification exam eligibility)

• Hold required coding/credentialing certification (AHIMA/AAPC level or specified CDI certification)

Benefits

A comprehensive federal employee benefits package; eligibility depends on appointment details.