Medical Records Technician (Coder In/Out)

Medical Record Technicians (MRT) Coders are responsible for classifying medical data from patient health records in the hospital or physician-based settings such as physician offices, group practices, multispecialty clinics, and specialty centers. MRTs analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. Major duties include but are not limited to: Assigns codes to inpatient admissions; develops skill and knowledge of health record coding. Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, to ensure ethical, accurate, and complete coding. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Codes inpatient admission to obtain the most appropriate MS-DRG, including all MCCs, CCs, correct POAs to support VERA and 3rd party reimbursement. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), and the Procedural Coding System (PCS). Selects diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy. Reviews health record documentation to abstract all required medical, surgical, demographic, social, and administrative data. Patient health records maybe paper or electronic. Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database. Operates a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access. Coding and documentation questions from providers are referred to a senior coder or supervisor for resolution or guidance. Work Schedule: Full time, Days Virtual/Remote Work Status: This position is eligible for Remote/Virtual work. However, this position may fall under the Presidential Memorandum titled "Return to In-Person Work" which requires you to go into the office. By applying to this position, you are acknowledging that you maybe be required to report in person to a designated location deemed by management. Functional Statement #: 402-F03429, F03469, F03468, F03467, F03478 Notifications: Current and former Federal employees must submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (Competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held.