Clinical Documentation Improvement Specialist - MRT Coder

US-Department-of-Veterans-Affair; Martinsburg (WV); On-site; USD 65,000 - 75,000; Full time

Job summary

The U.S. Department of Veterans Affairs at the Martinsburg VA Medical Center is seeking a Medical Records Technician (CDIS-Outpatient and Inpatient) to classify and abstract patient health records, assigning alphanumeric codes for diagnoses and procedures.

The role requires knowledge of medical terminology, anatomy, physiology, and coding systems. Applicants must meet basic requirements, including relevant education or certification and English proficiency.

Qualifications

• One year of creditable experience in medical terminology, coding, and health records.
• An associate's degree with coursework in health information management or related field.
• Completion of an AHIMA approved coding program leading to certification eligibility.
• Education/experience combinations allowed with specified substitutions.
• English language proficiency in speaking and writing.

Responsibilities

• Classify and abstract health records and assign ICD/ CPT/Procedure codes.
• Ensure documentation supports services rendered and complies with standards.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health records knowledge

Education

Associate degree in health information technology/health information management

AHIMA/AAPC coding program completion

Job description

The U.S. Department of Veterans Affairs at the Martinsburg VA Medical Center is seeking a Medical Records Technician (CDIS-Outpatient and Inpatient) to classify and abstract patient health records, assigning alphanumeric codes for diagnoses and procedures.

The role requires knowledge of medical terminology, anatomy, physiology, and coding systems. Applicants must meet basic requirements, including relevant education or certification and English proficiency.