Medical Records Technician - Inpatient

Job Summary Medical Records Technician (Coder) – Inpatient Facility (ICD-10-PCS) Location/Hours: Remote - Monday–Friday, 8:00am–4:30pm CT Client: Central Texas Veterans Health Care System (CTVHCS) – Temple, TX Compensation: $ 22.47/hr plus $5.09 for Health and Wellness Role Summary Responsible for accurate, timely facility inpatient coding and data validation across a broad range of specialties. Reviews medical records for complete documentation, assigns and sequences ICD-10-CM/PCS and related codes, and queries providers for clarification using VA tools. Primary Responsibilities Key Responsibilities Perform facility inpatient coding including ICD-10-CM, ICD-10-PCS, DRGs, and HCPCS as assigned. Review full medical record for principal diagnosis/procedures, complications/co-morbidities, and documentation adequacy. Ensure coding supports accurate billing and clinical/statistical reporting. Query clinicians for documentation clarification using VIRR (approved query format); close queries timely per requirements. Maintain 100% data validation for assigned encounters. Collaborate with claims/billing staff on documentation and coding/billing issues as needed. Support audits, corrective actions, and training efforts in coordination with the auditor and COR. Performance Standards (high level) Code records within 7 calendar days ( >95% compliance ). Maintain ≥95% accuracy for ICD-10-CM/PCS and related coding. Provide monthly QA/improvement reports and other ad hoc reporting as dire