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Medical Records Technician (CDIS Inpatient/Outpatient)
Veterans Health Administration · Posted 50 days ago
Hybrid New Orleans, LA $62K – $80K Apply by Aug 4, 2026 Medical Records Technician ISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System VA Medical Center. The Medical Records Technician (CDIS- Outpatient/Inpatient) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.
What You'll Do
- →Major duties for the position include (but are not limited to): Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
- →Selects and assigns codes from the current version of several coding systems to include current versions of the international Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- →Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
- →Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings used to classify patients under the Veterans Equitable Resources Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resources needs.
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
- →Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
- →Ensures provider documentation is complete and supports the diagnoses and procedures coded.
- →Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- →Reports incorrect documentation or codes in the electronic patient health record.
- →Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
- →Uses a variety of window-based applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
- →Ensures current versions of all software applications are loaded and functional after any updates or changes.
- →Collaboratively works with the professional clinical staff and provides support and education on documentation issues.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓Selective Service Registration is required for males born after 12/31/1959.
- ✓Must be proficient in written and spoken English.
- ✓Subject to background/security investigation.
- ✓Selected applicants will be required to complete an online onboarding process.
- ✓Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
- ✓Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- ✓Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- ✓Complete all application requirements detailed in the "Required Documents" section of this announcement.
- ✓Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position.
- ✓May require standing, lifting, carrying, sitting, stooping, bending, pulling, and pushing.
- ✓May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.
- ✓Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated.
Personality Fit
Job ID: 0d90fd32-cc87-4d1c-9760-ccfa51ddb32b
Posted via USAJobs