Medical Records Technician (Clinical Documentation Improvement - Outpatient Coder)

Quick Facts

• Role: Medical Records Technician (Clinical Documentation Improvement - Outpatient Coder)
• Focus: Outpatient coding and clinical documentation improvement (CDIS)
• Schedule: Monday–Friday, 8:00am–4:30pm (may change)
• Telework: Yes

Description

You will analyze and abstract information from patient health records and assign accurate diagnosis and procedure codes for outpatient encounters. The role requires applying current coding systems and guidelines (ICD-10-CM/ICD-10-PCS, CPT, HCPCS) and auditing coded data to ensure ethical, complete, and compliant documentation. You will also work with clinical staff to clarify and improve documentation so coded complexity and resource utilization are accurately reflected.

Responsibilities

• Code diagnoses and procedures using ICD-10-CM, ICD-10-PCS, CPT, and/or HCPCS in accordance with official coding guidelines
• Ensure correct selection of diagnosis, procedure, and evaluation/management (E/M) codes using accepted coding practices
• Apply VA-specific classification rules (including VERA) for accurate coding and reporting
• Monitor and remain compliant with changing regulatory and policy requirements affecting coded data
• Verify documentation in the patient record supports code assignment
• Perform audits to evaluate accuracy and completeness for outpatient coded data, including E/M assignment and modifier usage, supported by clinical documentation
• Provide coding guidance to improve accuracy and consistency across staff
• Conduct audits (develop criteria, collect data, graph/trend/analyze results), create reports, and communicate findings to leadership
• Support facility staff with documentation and coding requirements, including sequencing and reimbursement-related guidance

Requirements

• U.S. citizenship
• Proficiency in written and spoken English
• Subject to background/security investigation
• Pass pre-employment physical examination
• Selective Service registration required for eligible males
• Complete required onboarding and identification (I-9)
• Meet education/training or creditable experience requirements in medical terminology, anatomy/physiology, and medical coding
• Required certification/credentialing for MRT (Coder) roles (AHIMA/AAPC or AHIMA/CDIS as applicable)

Benefits

Comprehensive U.S. federal employee benefits package. Eligibility depends on the type of position held.