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Medical Records Technician - Inpatient Coder

Aptive

Responsible for accurate, timely inpatient facility coding supporting the VA Portland Health Care System. Reviews medical records for complete documentation and assigns/sequences ICD-10-CM, ICD-10-PCS, CPT/HCPCS, DRG, and related codes using VA systems such as VistA/CPRS.

Primary Responsibilities

  • Perform inpatient facility coding including ICD-10-CM, ICD-10-PCS, CPT/HCPCS, DRG, and E&M for all encounters assigned by VAPORHCS.
  • Access and review health record documentation in VA's VistA/CPRS system and enter codes into the approved coding application.
  • Apply modifiers, CCI bundling guidelines, and Reason Not Billable (RNB) designations as appropriate.
  • Code all standard cases within 7 calendar days of receipt/discharge; priority cases within one business day.
  • Clarify conflicting, ambiguous, or nonspecific record information by consulting with the contract coder supervisor.
  • Comply with HIPAA, VA/VHA privacy, security, and records management directives, and complete required VA training prior to system access and annually thereafter.
  • Follow AHIMA Standards of Ethical Coding.
Requirements & Qualifications

Minimum Qualifications

  • Active coding credential from AHIMA (RHIA, RHIT, CCS, or CCS-P) or AAPC (CPC or CPC-H); credential must be maintained for the duration of the contract.
  • Minimum 2 years of experience in inpatient coding.
  • Proficiency with ICD-10-CM, ICD-10-PCS, CPT/HCPCS, DRG assignment, and E&M guidelines.
  • Ability to work within VA systems such as VistA/CPRS and VIRR, and comply with HIPAA/VA directives.
  • U.S. citizenship required.

Location

N/A

Employment Type

Full-time

Experience Level

Intermediate Level

Remote work allowed

Yes

Posted

2 months ago

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