Medical Coder

DTSV, Inc.; Cleveland (OH); On-site; USD 60,375,000 - 76,305,000; Full time

Job summary

VA Northeast Ohio Healthcare System in Cleveland, OH, is seeking a Medical Records Technician (MRT) Coder to review, analyze, and code patient records according to VA policies and industry standards. The role covers inpatient, outpatient, and ambulatory surgery coding in a large tertiary-care VA system, with duties that include DRGs, ICD-10-CM/PCS, CPT, and HCPCS.

Confidentiality and VA compliance are essential.

Qualifications

• Minimum of two 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.
• Experience coding complex medical records in an acute care healthcare environment.

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

VA coding experience

Inpatient/outpatient coding

HIPAA compliance

Education

AHIMA Certification

AAPC Certification

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.