Medical Records Coder - Inpatient & Outpatient Expert

AAPC; Cleveland (OH); On-site; USD 29,000 - 37,000; Full time

Job summary

The VA Northeast Ohio Healthcare System is seeking a Medical Records Technician (MRT) Coder to accurately review, analyze, and code patient records for inpatient, outpatient, and ambulatory surgery within a large tertiary-care VA system.

Responsibilities include coding using DRGs, ICD-10-CM/PCS, CPT/HCPCS, abstracting EHR data, and ensuring compliance with VA and federal standards while maintaining patient confidentiality.

Qualifications

• 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.
• Candidates must possess at least one of the following certifications: AHIMA or AAPC.

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

HIPAA

Job description

The VA Northeast Ohio Healthcare System is seeking a Medical Records Technician (MRT) Coder to accurately review, analyze, and code patient records for inpatient, outpatient, and ambulatory surgery within a large tertiary-care VA system.

Responsibilities include coding using DRGs, ICD-10-CM/PCS, CPT/HCPCS, abstracting EHR data, and ensuring compliance with VA and federal standards while maintaining patient confidentiality.