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 role involves working with a major acute care teaching and research institution that provides a broad spectrum of healthcare services, including acute care, domiciliary services, Community Living Centers, Nursing Home Care Units, ambulatory surgery, and telehealth programs.
Key responsibilities include:
- 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
- United States citizenship required
- Proficiency in spoken and written English
- 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
- Demonstrated experience coding complex medical records in an acute care healthcare environment
- At least one of the following certifications:
- AHIMA certification
- AAPC certification
- Preferred:
- 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
Location
Cleveland, Ohio, US
Employment Type
Not specified
Experience Level
Intermediate Level
Remote work allowed
No
Posted
1 month ago