Medical Records Technician – Inpatient/Outpatient Coder

CVP is seeking Medical Records Technicians (Inpatient/Outpatient Coders) to join our team in providing medical coding services in support of the Captain James A. Lovell Federal Health Care Center (FHCC) located in North Chicago, IL.

This is a fully remote position, with working hours of Monday through Friday, 7:30am - 4:00pm CST. The FHCC serves over 75,000 Veterans from the northeastern Illinois and southeastern Wisconsin area, operating 354 inpatient beds and seeing approximately 215,000 inpatient admissions and outpatient visits annually.

• →Review health care provider medical record coding for completeness and accuracy, and clarify and correct provider coding as necessary.
• →Query providers via encrypted Outlook email using the Provider Query Foundation OneNote to ensure accurate coding reporting, in compliance with VHA HIM Practice Brief standards.
• →Abstract medical, surgical, laboratory, pharmaceutical, radiologic, demographic, social, and administrative data from the medical record in a timely manner, ensuring all diagnoses and procedures are identified, documented, sequenced correctly, and coded accurately.
• →Determine the most appropriate codes for routine and/or new and unusual diagnoses and procedures not clearly listed in ICD-10-CM, ICD-10-PCS, CPT, and HCPCS.
• →Review and screen entire medical records to ensure all conditions and care rendered are appropriately documented, coded, and sequenced in accordance with coding compliance guidelines and the National Correct Coding Initiative.
• →Ensure physician documentation supports the diagnoses and procedures coded, contacting clinicians via e-mail or face-to-face meetings as necessary.
• →Concurrently code inpatient encounters when not completing assigned discharged cases (inpatient coders only).
• →Query clinicians using encrypted Outlook emails and 3M/Solventum 360 for clarification of conflicting or ambiguous information, ensuring all queries are closed no later than 30 days after the date of discharge or service.
• →Maintain coding accuracy at 95% or greater in accordance with contract performance standards.
• →Maintain the accuracy of diagnostic and procedural statistics for the facility to support optimum appropriate reimbursement from third-party payers.
• →Keep abreast of regulatory changes affecting coded information as required by the Centers for Medicare and Medicaid Services (CMS) and other applicable regulatory bodies.
• →Comply with all HIPAA standards, VHA Coding Guidelines, and all relevant civilian and VA Handbooks and Directives, including those of the Joint Commission, AMA, AHA, and CMS.
• →Maintain privacy and confidentiality of all patient records and sensitive information in accordance with the Privacy Act and applicable VA/VHA directives.

• Ability to successfully undergo a Government-sponsored background investigation; US Citizenship is required, and must be proficient in spoken and written English.
• Associate's degree from an accredited college or university with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management; a bachelor's degree is preferred.
• Minimum of three (3) years of continuous coding experience in a facility having a patient population equal to or exceeding the VA's current patient population.
• Must possess at least one of the following active certifications:
  • Registered Health Information Technician (RHIT) - AHIMA
  • Certified Coding Specialist (CCS or CCS-P) - AHIMA
  • Registered Health Information Administrator (RHIA) - AHIMA
  • Certified Professional Coder (CPC) - AAPC
• Demonstrated knowledge of Oracle Cerner applications, 3M/Solventum application, ICD-10-CM, ICD-10-PCS, CPT, Evaluation and Management (E/M) Level Coding, and HCPCS.
• Strong working knowledge of MS-DRG logic, CC/MCC capture, POA indicators, and National Correct Coding Initiative (NCCI) guidelines.
• Familiarity with medical terminology, anatomy, physiology, and healthcare documentation standards.
• Experience with inpatient surgical coding, including complex scenarios such as multiple procedures, staged procedures, revisions, returns to OR, and device replacements is preferred.
• Prior VA or federal healthcare system coding experience is preferred.

• Remote support for the Captain James A. Lovell Federal Health Care Center (FHCC) located in North Chicago, IL.

• Monday through Friday, 7:30am - 4:00pm CST.