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Medical Records Technician – Inpatient Coder
Aptive ResourcesInpatient Coder managing accurate coding of medical records for the VA Portland Health Care System. Ensuring compliance with coding standards and timely submission of coded records.
About the role
Key responsibilities & impact- Responsible for accurate, timely inpatient facility coding supporting the VA Portland Health Care System.
- Reviews medical records for complete documentation, assigns and sequences ICD-10-CM/PCS, CPT/HCPCS, DRG, and related codes via VA systems (VistA/CPRS).
Requirements
What you’ll need- 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; 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 all HIPAA, VA/VHA privacy, security, and records management directives, and complete all required VA training prior to system access and annually thereafter.
- Comply with AHIMA Standards of Ethical Coding.
Benefits
Comp & perks- 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 (e.g., VistA/CPRS, VIRR) and comply with HIPAA/VA directives.
- U.S. citizenship
ATS Keywords
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Hard Skills & Tools
ICD-10-CMICD-10-PCSCPTHCPCSDRGE&M codingmedical record reviewcoding applicationmodifiersCCI bundling guidelines
Soft Skills
attention to detailcommunicationproblem-solvingconsultationtime management
Certifications
AHIMA Standards of Ethical Coding