Medical Records Coder — Acute Care & DRG Expert

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

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.