Medical Records Coder (Outpatient)

Quick Facts

• Remote (100%)
• Schedule: Monday–Friday, 7:00am–3:30pm

Description

The Medical Records Coder (Outpatient) role classifies and codes patient care encounters by reviewing medical records, assigning diagnosis and procedure codes, and ensuring coded data is accurate and complete for outpatient/ambulatory services.

The position uses ICD, CPT, and HCPCS coding conventions, abstracts clinical and administrative data, and transmits coded records to the national VA database, including correcting errors and meeting VERA program requirements.

Responsibilities

• Assign appropriate diagnosis, procedure, and E/M codes for outpatient and inpatient professional services based on documentation
• Abstract required medical, surgical, ancillary, demographic, social, and administrative data from health records
• Select codes from current ICD and CPT/HCPCS code sets and apply official coding conventions and guidelines
• Ensure provider documentation is complete enough to support diagnoses and procedures coded
• Search health records to justify code assignments using the organization’s record structure
• Use VistA/CPRS and coding/encoder software to code, abstract, record, and transmit data; correct inconsistencies within established timelines
• Perform re-reviews for outpatient encounters identified by the VERA committee and correct coding as needed
• Code inpatient professional fee services for admissions with compliance to fraud and abuse guidelines and VA guidance
• Code outpatient ambulatory surgical cases and add anesthesia/pathology codes to the appropriate patient care encounter
• Review community (non-VA) outpatient fee service encounters and code diagnoses from paper or electronic documentation
• Code diagnoses for VA registries (e.g., Agent Orange, Ionizing Radiation, Persian Gulf, POW)

Requirements

• U.S. citizenship
• Complete all required application steps including an online assessment
• Proficient in written and spoken English
• Subject to background/security investigation
• Pass pre-employment physical evaluation
• Complete pre-employment onboarding and identification requirements (I-9)
• Seasonal influenza vaccination is required
• Selective Service registration is required for eligible males
• Certification required (AHIMA/AAPC apprentice/associate or mastery level; or AHIMA/ACDIS CDI certification; or applicable grandfathering)
• Basic qualifications via experience OR qualifying education OR approved intensive coding training (≈1 year+) leading to certification eligibility

Benefits

• Competitive salary with regular salary increases
• Paid time off: 37–50 days annual paid time off per year (annual leave, sick leave, paid federal holidays)
• Parental leave after 12 months (up to 12 weeks paid)
• Child care subsidy after 60 days (income-based)
• Federal retirement pension and 401K with up to 5% contributions
• Federal health/vision/dental/term life/long-term care insurance options
• Remote 100% telework (outside the area)