Medical Records Technician (Remote) - Inpatient

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.

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

• 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 directed.

Required Qualifications

• Minimum Qualifications: Active certification: RHIT, RHIA, CCS, CCS-P, and/or CPC (must maintain throughout contract).
• 3+ years continuous coding experience in a comparable or larger facility setting.
• Proficiency with ICD-10-CM, ICD-10-PCS, DRGs, HCPCS and facility coding workflows.
• U.S. citizen, proficient in written/spoken English.
• Ability to work within VA systems (e.g., VistA/CPRS, VIRR) and comply with HIPAA/VA directives.

About Aptive

Aptive is an equal opportunity employer. We consider all qualified applicants for employment without regard to race, color, national origin, religion, creed, sex, sexual orientation, gender identity, marital status, parental status, veteran status, age, disability, or any other protected class. Veterans, members of the Reserve and National Guard, and transitioning active-duty service members are highly encouraged to apply.