Medical Records Technician

Job Title: Medical Records Technician Coder (Inpatient & Outpatient)

Specialty: ICD-10-CM, ICD-10-PCS, CPT, HCPCS Coding (Inpatient & Outpatient)

Site: Central Texas Veterans Health Care System (CTVHCS)

Location: Temple, Texas

Duration: 6 months and extendable

Shift Schedule: Monday Friday, 8:00 AM 4:30 PM CT

Shifts per Month: Full-time schedule (40 hours/week)

Certifications Required:

Candidate must hold at least one of the following active credentials:

• RHIT Registered Health Information Technician
• RHIA Registered Health Information Administrator
• CCS / CCS-P Certified Coding Specialist
• CPC Certified Professional Coder
  
  (All certifications must be active and maintained throughout the contract.)

Experience Needed:

• Minimum 3 years of continuous coding experience in a facility with a patient population comparable to the VA.
• Experience with ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and E/M coding.
• Ability to code inpatient and outpatient encounters with 95% accuracy or higher.
• Experience working within complex healthcare environments (preferably tertiary-level or academic medical centers).

Special Skills:

• Proficiency with VistA, CPRS, VIRR, encoder applications, and EHR systems.
• Ability to review entire medical records and abstract clinical, surgical, diagnostic, and demographic data.
• Strong knowledge of HIPAA, VA privacy guidelines, and national coding rules.
• Ability to meet strict timeliness and accuracy standards.
• Capable of communicating professionally with providers regarding coding queries.

Credentialing / Onboarding Time: Approximately 6 8 weeks (based on VA background checks and system access requirements)

Responsibilities:

• Review and accurately code inpatient and outpatient medical records, including surgeries, procedures, primary care, subspecialties, ambulatory surgery, observation, and endoscopy encounters.
• Assign ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and E/M codes in compliance with CMS, VA, and national coding guidelines.
• Validate 100% of assigned encounters and ensure documentation supports all codes assigned.
• Review medical records for accuracy, completeness, sequencing, and compliance with Federal/VA standards.
• Query providers via VistA Integration Revenue & Reporting (VIRR) when clarification is needed and ensure queries are resolved within required timelines.
• Perform thorough data abstraction from medical records for administrative and clinical reporting.
• Remain current on regulatory changes and coding guideline updates (CMS, AMA, AHA, VA, etc.).
• Participate in required meetings, audits, training, and quality review sessions as directed by the COR.

Miscellaneous:

• Must comply with all VA privacy, HIPAA, and information security requirements.
• Required to complete annual VA training (HIPAA, security, compliance, patient safety, etc.).
• Must obtain and maintain VA PIV card and pass federal background investigations.

Prime Physicians is a physician-led, The Joint Commission (TJC) Accredited, ISO 9001 certified and CMMI Level 3 appraised organization. Our commitment extends beyond traditional consulting and management services, offering comprehensive solutions to hospitals, health systems, and federal government agencies. At the heart of our operations is the ultimate goal to deliver high-quality patient care. Driven by a mission to catalyze healthcare transformation and innovation, we offer an array of services designed to redefine the healthcare landscape. From program and project management to strategic planning, we enhance operational efficiency and streamline business processes. With Prime Physicians, the future of patient care is in skilled and dedicated hands, leading the way towards a more efficient, effective, and compassionate healthcare system.