Remote Clinical Documentation Specialist (CDIS - Inpatient)

U.S. Department of Veterans Affairs; Gary (IN); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Remote work eligible

Job summary

The U.S. Department of Veterans Affairs seeks a Medical Records Technician (CDIS-Inpatient) to classify and code medical data from health records in inpatient settings, using ICD-10-CM/PCS, CPT, and related coding systems. You will review records, ensure documentation supports codes, and educate staff on documentation and coding practices.

Requirements include U.S. citizenship, English proficiency, and either an associate degree in health information technology/health information management or

Qualifications

• Knowledge of medical terminology, anatomy and physiology, medical coding, and health record structures.
• Proficiency in ICD-10-CM/PCS and CPT coding guidelines would be beneficial.
• Ability to communicate clearly with clinical staff regarding documentation and coding requirements.

Responsibilities

• Demonstrates expertise in ICD-10-CM/PCS, CPT coding and the Health Care Coding System.
• Reviews clinical documentation for completeness and accuracy to support proper coding.
• Provides education to clinicians on documentation and coding practices to improve accuracy.

Education

Associate's degree in health information technology/health information management

AHIMA or AAPC coding certification program completion

Job description

The U.S. Department of Veterans Affairs seeks a Medical Records Technician (CDIS-Inpatient) to classify and code medical data from health records in inpatient settings, using ICD-10-CM/PCS, CPT, and related coding systems. You will review records, ensure documentation supports codes, and educate staff on documentation and coding practices.

Requirements include U.S. citizenship, English proficiency, and either an associate degree in health information technology/health information management or