Inpatient Medical Records Coder | Telework Eligible

U.S. Department of Veterans Affairs; San Diego (CA); On-site; USD 70,000 - 100,000; Full time

Job summary

U.S. Department of Veterans Affairs in San Diego, CA is seeking a Medical Records Technician (Coder) to classify and code medical data from patient records in hospital and physician-based settings.

The role requires analyzing records, assigning ICD-10-CM/PCS and CPT/HCPCS codes, and ensuring accurate DRG outcomes. The position emphasizes collaboration with clinical staff to clarify ambiguous data, maintain high data quality, and ensure proper documentation supports coding decisions.

Qualifications

• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, medical coding, and health records
• Education options include an associate's degree with HIM/health information coursework or AHIMA/AAPC coding program leading to certification eligibility
• Flexibility to combine education and experience as allowed by VA standards
• Certification through AHIMA or AAPC preferred for MRT (Coder) positions

Responsibilities

• Select and assign codes from ICD-10-CM/ICD-10-PCS and CPT/HCPCS for inpatient facility and professional services
• Review documentation to ensure adequate support for codes and DRG assignment
• Abstract and encode clinical data to ensure medical necessity and data accuracy
• Consult with clinical staff for clarification of conflicting or incomplete data

Skills

Medical terminology

Anatomy & physiology

Medical coding

Health record techniques

English language proficiency

Education

Associate's degree in health information technology/health information management

AHIMA or AAPC coding certification program

Tools

Encoder software

Job description

U.S. Department of Veterans Affairs in San Diego, CA is seeking a Medical Records Technician (Coder) to classify and code medical data from patient records in hospital and physician-based settings.

The role requires analyzing records, assigning ICD-10-CM/PCS and CPT/HCPCS codes, and ensuring accurate DRG outcomes. The position emphasizes collaboration with clinical staff to clarify ambiguous data, maintain high data quality, and ensure proper documentation supports coding decisions.