Jul 24, 2026

Medical Records Technician (Coder-Outpatient)

Job Description

Duties

Help. Total Rewards of an Allied Health Professional Duties may include, but are not limited to:

  • Completes diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.
  • Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Note: Coders will follow current published ICD-10-CM Official Guidelines for Coding and Reporting, CPT Guidelines, as well as other established industry standard coding guidance such as the American Medical Association (AMA) CPT Assistant and the American Hospital Association's (AHA) Coding Clinic.
  • Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS.
  • Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC.
  • Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
  • Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
  • Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations.
  • 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.
  • Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the electronic health record.
  • Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases.
  • Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.
  • Researches references to resolve any questionable code errors, contacts supervisor as appropriate.
  • Codes inpatient professional fee services for identified inpatient admissions.
  • Codes all identified surgical procedures.

Work Schedule: Monday through Friday 8am - 4:30pm

Compressed/Flexible: Authorized

Recruitment Incentive (Sign-on Bonus): Not Authorized

Permanent Change of Station (Relocation Assistance): Not Authorized

Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

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.

Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA

Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)

Telework: Ad-Hoc only

Virtual: This is not a virtual position.

Permanent Change of Station (PCS): Not Authorized