Inpatient/Outpatient Medical Coder

DaMar Staffing; Cleveland (OH); On-site; USD 52,000 - 76,000; Full time

Job summary

Posterity Group LLC is staffing Louis Stokes Cleveland VA Medical Center with In/Outpatient Remote Medical Coders. The Medical Coder will attach and verify images in EHRs, index records, and perform QA.

They will code across inpatient, outpatient, and surgical specialties, adhering to ICD-10-CM/PCS, CPT/HCPCS and E/M guidelines, with strict performance targets. Requirements include AHIMA/AAPC certification, VA facility experience, US citizenship, and ability to work within the VHA processes and

Qualifications

• At least one current coding certification from AHIMA or AAPC.
• Two years of continuous professional coding experience in a VA facility or equivalent.
• U.S. citizenship and proficiency in English (spoken and written).
• Ability to code across inpatient, outpatient and surgical specialties.
• Proficiency in ICD-10-CM, ICD-10-PCS, CPT, HCPCS and E/M guidelines.

Responsibilities

• Attach images to appropriate EHR elements and ensure legibility.
• Verify images uploaded correctly and linked to veteran records.
• Index documents by section, note title, date of service and visit location.
• Perform 100% internal QA before submission.
• Process inpatient, outpatient coding within five days of assignment; surgery coding after procedure when possible; target >95% compliance.
• Handle re-codes, rejects and corrections promptly; maintain accuracy targets.

Education

AHIMA/AAPC coding certifications (RHIT, RHIA, CCS, CCS-P, CPC, COC, CIC)

Tools

Oracle Health coding

VistA CPRS VIRR

Job description

Medical Coder

Posterity Group LLC is a veteran owned, service-disabled small business, headquartered in Rockville, MD, that specializes in federal government contracting and staffing. We are tasked with staffing Louis Stokes Cleveland VA Medical Center with In/Outpatient Remote Medical Coders. The Medical Coder is expected to do the following:

• Accurately attaching images to the appropriate electronic health record elements.
• Verifying that images are uploaded correctly and are legible for viewing.
• Locating Financial Identification Numbers (FINs) and accurately linking documents to the correct veteran record.
• Indexing documents within the correct section, note title, date of service, and visit location.
• Performing 100% internal QA on all work before submission.
• Process Inpatient, Outpatient coding within five (5) calendar days of assignment, surgery coding completed immediately after the procedure when possible and no later than five (5) calendar days from the date coding is assigned, goal of greater than 95% compliance.
• Process all re-codes, rejects, and corrections without delay once reassigned, goal of greater than 95% compliance.

Requirements

• At least one current coding certification from AHIMA or AAPC (RHIT, RHIA, CCS, CCS-P, CPC, COC, CIC).
• A minimum of two (2) years of continuous professional coding experience in a VA facility comparable in size and complexity to VA Northeast Ohio Healthcare System, or equivalent.
• United States citizenship and proficiency in spoken and written English.
• Demonstrated ability to code across all major inpatient, outpatient, and surgical specialties.
• Demonstrate proficiency in applying appropriate coding conventions across all care settings, including inpatient, outpatient, professional services, and surgical encounter/FINs. Required competencies include ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and E/M guidelines, or the applicable combination based on assigned coding responsibilities.
• Ability to query providers and resolve documentation discrepancies following the VHA Provider Query Process.
• Proficiency in Oracle Health coding processes and familiarity with legacy systems (VistA, CPRS, VIRR).
• Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
• Ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
• Ability to accurately perform the full scope of assigned coding, including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounter/FINs, inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
• Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
• Ability to meet or exceed 3 inpatient PTFs (to include professional and surgery services as applicable); 25 outpatient/prosthetics services encounter/FINs; 9 surgical services encounter/FINs (to include anesthesia and pathology as applicable) per day.
• Demonstrate ability to review all Service Connection and Service Authority questions (Service Connected, Agent Orange, Ionizing Radiation, Head and Neck Cancer, Military Sexual trauma and Combat Veteran) at the diagnosis level when prompted and assign to facility Utilization Review Nurse if appropriate.
• Exclude from coding information such as symptoms or signs characteristic of the definitive diagnoses, findings from diagnostic studies or localized conditions that have no bearing on current management of the patient.