Medical Records Techician (Coder Outpatient)

This position is located in the Health Information Management (HIM) section at the Southern Arizona VA Health Care System (SAVAHS). 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.

Duties include, but are not limited to: Outpatient MRTs (Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services.

Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management services.

They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.

They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties.

They also directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.

MRTs (Coder) must abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.

They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.

They also query clinical staff with documentation requirements to support the coding process.

They enter and correct information that has been rejected, when necessary.

MRTs (Coder) ensure audit findings have been corrected and refiled.

They also use various computer applications to abstract records, assign codes, and record and transmit data.

Work Schedule: Monday - Friday 7:30 am - 4:00 pm Telework: Not Available Virtual: This is NOT a virtual position.

Remote: This is NOT a remote position.

Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized