Medical Coder

DTSV, Inc.; Cleveland (OH); On-site; USD 44,000 - 55,000; Full time

Job summary

VA Northeast Ohio Healthcare System in Cleveland is seeking a Medical Records Technician (MRT) Coder to review, analyze, and code patient records in accordance with VA policies, federal regulations, and industry standards.

You will code inpatient, outpatient, and ambulatory surgery encounters, maintain HIPAA compliance, and collaborate with providers to clarify documentation. U.S. citizenship and VA coding experience required.

Qualifications

• Review and code medical records in accordance with VA policies and industry standards.
• Code inpatient, outpatient, and ambulatory surgery encounters.
• Maintain HIPAA compliance and protect patient information.

Responsibilities

• Review and analyze medical documentation to assign accurate diagnosis and procedure codes.
• Perform facility medical record coding for inpatient, outpatient, and ambulatory surgery encounters.
• Ensure coding accuracy, completeness, and compliance with VA, federal, and industry standards.
• Abstract and code clinical information from electronic health records.
• Meet established productivity and quality standards.
• Collaborate with providers and healthcare staff to clarify documentation and coding requirements.
• Maintain confidentiality and protect patient information in accordance with HIPAA and VA regulations.

Skills

DRGs

ICD-10-CM

ICD-10-PCS

CPT

HCPCS

Productivity standards

HIPAA compliance

Job description

Description

The Medical Records Technician (MRT) Coder is responsible for accurately reviewing, analyzing, and coding patient medical records in accordance with federal regulations, VA policies, and industry coding standards. Coders will support inpatient, outpatient, and ambulatory surgery services within a large, complex tertiary-care Veterans Affairs healthcare system.

The VA Northeast Ohio Healthcare System is an acute care teaching and research institution accredited by The Joint Commission and affiliated with medical schools, residency programs, universities, and colleges. The facility provides a broad spectrum of healthcare services, including acute care, domiciliary services, Community Living Centers (CLC), Nursing Home Care Units (NHCU), ambulatory surgery, and telehealth programs.

• Review and analyze medical documentation to assign accurate diagnosis and procedure codes.
• Perform facility medical record coding for inpatient, outpatient, and ambulatory surgery encounters.
• Ensure coding accuracy, completeness, and compliance with VA, federal, and industry standards.
• Utilize and maintain proficiency in:
  • Diagnosis Related Groupings (DRGs)
  • ICD-10-CM
  • ICD-10-PCS
  • CPT
  • HCPCS
• Abstract and code clinical information from electronic health records.
• Meet established productivity and quality standards.
• Collaborate with providers and healthcare staff to clarify documentation and coding requirements.
• Maintain confidentiality and protect patient information in accordance with HIPAA and VA regulations.

This position offers an hourly rate ranging from $21.07 to $26.63.

Requirements

• United States citizenship required.
• Proficiency in spoken and written English.
• Minimum of two (2) years of continuous coding experience within a VA healthcare facility serving a patient population equal to or greater than that of the VA Northeast Ohio Healthcare System.
• Demonstrated experience coding complex medical records in an acute care healthcare environment.

Required Certifications

Candidates must possess at least one of the following certifications:

• AHIMA Certifications
• AAPC Certification

Preferred Qualifications

• Experience working within large, academically affiliated healthcare systems.
• Knowledge of teaching hospital coding practices.
• Experience supporting ambulatory surgery, inpatient, outpatient, and specialty care services.
• Familiarity with VA electronic health record systems and coding compliance requirements.