Medical Records Technician (Coder- Inpatient)

Summary The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder-Inpatient) position. The Medical Records Technician (Coder-Inpatient) is located in the Health Information Management Services (HIMs) section within Patient Care Administrative Service. Responsibilities Major duties of the Medical Records Technician (Coder - Inpatient) include, but are not limited to: Reviewing record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data, and query clinical staff, as appropriate, with guidance from higher level MRTs (Coder). Use various computer applications to abstract records, assign codes, and record and transmit data. They ensure audit findings have been corrected and refiled. Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. Has basic knowledge of medical terminology, anatomy &...