Job Listing
Medical Records Technician (Coder-Outpatient and Inpatient)
Veterans Health Administration · Posted 63 days ago
Hybrid Montgomery, AL $36K – $73K Apply by Jul 24, 2026 Medical Records Technician ESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) section at the Central Alabama Veterans Health Care System (CAVHCS). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.
What You'll Do
- →Total Rewards of a Allied Health Professional Major duties may include, but are not limited to: Applies knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and/or inpatient professional services.
- →Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
- →With instruction from a senior coder or supervisor learns to select diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions and policy.
- →Assigns codes to documented patient care encounters (outpatient professional services); encounters are routine and less complex or for only one specialty or subspecialty.
- →Selects and assigns codes from the current version of the International Classification of Diseases (ICD) Clinical Modification (CM), 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 (E/M) code to ensure ethical, accurate, and complete coding.
- →Also adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation.
- →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.
- →Establishes the primary and secondary diagnosis and procedure codes for outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.
- →Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; identifies non-billable encounters.
- →HCPCS codes are used per guidelines.
- →Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes using the current code set and the encoder product suite; ensures all procedures file to the appropriate Patient Care Encounter (PCE); adds Anesthesia and Pathology codes to the PCE encounter for all billable surgical cases.
- →Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.
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 identification 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.
- ✓As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
- ✓In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service.
- ✓Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.
- ✓Note: Only education or degrees recognized by the U.S.
Personality Fit
Job ID: d395d8cf-37d8-4e5f-8462-7b05c382e94c
Posted via USAJobs