3652 medical records jobs found

Medical Records Technician (Coder) This position is in the Health Information Management (HIM) section of the Health Administration Service at the Fargo Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Major duties include, but are not limited to, the following: 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 & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties. Coding systems include current versions of the International Classification of Diseases (ICD), Current Procedural...

Summary This position is in the Health Information Management (HIM) section of the Health Administration Service at the Fargo Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Duties Help Total Rewards of a Allied Health Professional This position requires the incumbent to physically report for work to the Fargo ND VAMC. Major duties include, but are not limited to, the following: 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 & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection. Selects and assigns codes from the current version of one or more coding systems depending on...

Salary Range: $24.00 - $29.00 Hourly Role and Responsibilities Responsible for all activities related to order compliance and management of physician data in system(s); this position assures optimal regulatory compliance. Essential Functions Monitor orders which are in Mosia escalation folder and perform necessary follow - up. Provide education and support to Medical Records staff as it pertains to Mosia and indexing, to ensure timely and appropriate foll-up. Monitor reports and Mosia tracking features to assure goals of Orders Lifecycle are met. Perform follow up related to timely receipt of unsigned Orders including calls to physician offices and communication with Clinical team members/managers to resolve issues as needed. Elevate unresolved issues to Team Leader or Manager Document actions in system to support compliance with internal policies and regulatory guidelines. Verify credentials including licensing, NPI, PECOS, OPRA, and...

Summary This position is in the Coding Section at the VA Maryland Health Care System (VAMHCS). The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. This is considered the full performance level for this assignment. Coders at this level perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Duties Help Major Duties may Include: Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. All diagnoses and procedure codes are selected...

Summary The Medical Records Technician (Coder) Auditor is located in the Health Information Management (HIM) section of Medical Administration Service at the VA Maryland Health Care System. A Medical Records Technician must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), the Healthcare Common Procedure Coding System (HCPCS) and be skilled in classifying medical data from patient health records. Responsibilities Total Rewards of a Allied Health Professional Duties: Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Reviews assigned codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural...

Summary This position is located in the Health Information Management (HIM) section at the Durham VA Medical Center. MRTs (Coder-Inpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Responsibilities Select and assign codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).Review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record. Use variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; develops use of the health...

Summary This position is in the Health Information Management (HIM) section at the Durham VA Health Care System. The Medical Record Technician (Coder) Auditor is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Responsibilities The duties of the Auditor will include, but are not limited to: Serves as expert of current coding conventions and regulations related to professional and facility coding. Performs audits of encounters to identify areas of non-compliance in coding. Provides recommendations on appropriate coding and is responsible for maintaining current knowledge of the various regulatory guidelines and requirements. Works with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective actions. Performs prospective coding audits and utilizes results to identify processing inadequacies and...

Salary: $45,907.00 - $69,203.00 Annually Location : Somerset County, PA Job Type: Civil Service Permanent Full-Time Job Number: CS-2026-41213-39010 Department: Department of Corrections Division: CR LAU Med Opening Date: 01/23/2026 Closing Date: 2/5/2026 11:59 PM Eastern Job Code: 39010 Position Number: 00232530 Union: AFSCME Bargaining Unit: A2 Pay Group: ST05 Bureau / Division Code: 00114430 Bureau / Division: State Correctional Institution at Laurel Highlands Worksite Address: 5706 Glades Pike City: Somerset, Pennsylvania Zip Code: 15501 Contact Name: Corleen Schmucker Contact Phone: 717.562.5736 Contact Email: cschmucker@ THE POSITION Are you a detail-oriented professional with an unwavering commitment to data integrity and patient privacy? The Department of Corrections (DOC), State Correctional Institution (SCI) at Laurel Highlands is looking for a Medical Records Supervisor. In this key role, you will bridge...

Medical Records Technician (Coder-Inpatient) This position is located in the Health Information Management (HIM) section at the Durham VA Medical Center. MRTs (Coder-Inpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Responsibilities include: Select and assign codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record. Use variety of computer applications in day to day activities and duties, such as...

Responsibilities HIM/Medical Records Analyst/Coding Specialist Opportunity West Oaks Hospital has provided psychiatric care to the Houston area and surrounding communities for over four decades. Our 176-bed acute care facility is fully accredited and included a 16-bed residential treatment center for adult chemical dependency. We offer a broad range of behavioral health programs for children, adolescents and adults. Treatment is offered at multiple levels of care including inpatient, partial hospitalization and intensive outpatient. We are available 24 hours a day, seven days a week to assist you and answer your questions about treatment options and insurance coverage. The hospital is easily accessible off the Southwest Freeway near the Galleria. Visit us online at: https://westoakshospital.com/ West Oaks Hospital is seeking a dynamic and talented HIM/Medical Records Coding Specialist to join our team of compassionate, dedicated professionals. The HIM/Medical...

Job Summary Under general supervision and according to established procedures, provides technical support to the Inpatient Coding Staff and coordinates daily workflow based on the needs of the department. On a daily basis, provides the Coding Manager with departmental statistics such as the monitoring/tracking of Inpatient coder productivity and uncoded figures. Works with the Coding Manager and Coding Educator to identify and resolve coding issues. Serves as the primary contact for outside departments for Inpatient coding related questions. Reports to the Director of Medical Records and the Coding Manager a list of aged accounts. Follow-up with the Medical Records Staff and/or Physician as necessary to obtain required documentation to code all accounts in a timely manner. Provides coding support as directed by the Coding Manager. Essential Functions Provides technical coding support to the Inpatient Coding Staff and coordinates daily workflow based on the needs of the...

A leading rehabilitation hospital in Pennsylvania is seeking a HIMS Supervisor. This pivotal role involves overseeing HIMS functions, ensuring compliance with regulatory standards, and optimizing medical records systems. The ideal candidate will have supervisory experience in HIMS and possess relevant certifications. This position offers competitive benefits and a commitment to fostering a diverse and inclusive workplace culture. #J-18808-Ljbffr

Summary MRTs are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients. health records and assign alphanumeric codes for each diagnosis and procedure. Responsibilities THIS IS AN ON SITE POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION Duties of the Medical Records Technician (Coder) In/Outpatient include, but not limited to: Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to...

Medical Records Technician Coder I Koniag Advisory Business, a Koniag Government Services company, is seeking a Medical Records Technician Coder I to support Koniag Advisory Business and our government customer in Poplar, MT. This position requires the candidate to be able to obtain a Public Trust. We offer competitive compensation and an extraordinary benefits package including health, dental and vision insurance, 401K with company matching, flexible spending accounts, paid holidays, three weeks paid time off, and more. Key Responsibilities Medical Coding: Perform quantitative analysis of medical records to ensure completeness and accuracy Assign CPT/HCPCS/CDT/DSM codes in accordance with AHIMA and AMA guidelines Ensure proper Evaluation & Management (E&M) levels are applied Sequence diagnostic and procedural terminology accurately Ensure compliance with official coding conventions and regulations Medical Records Management: Scan medical documents into...

Medical Records Certified Coder Opportunity Full Time, Dayshift Monday-Friday, Inperson $2,500 Sign On Bonus As the only free-standing psychiatric hospital in the Central Kentucky area, we are here to help. Please join our team as we expand our services to meet the needs of our community. The Ridge Behavioral Health System is a 110-bed hospital located in the heart of the Bluegrass, Lexington, KY. The Ridge provides psychiatric and substance use disorder treatment for children, adolescents, and adults. The Ridge offers Partial Hospitalization, Intensive Outpatient Programs, Individual Counseling, as well as Medication Management for all ages. We have provided behavioral health services to over 92 Kentucky counties for more than 39 years. Job Duties Include: Meets coding quality score of 95% accuracy in assignment of diagnoses and procedure codes as measured by the quarterly coding audit performed by Corporate. Coordinate treatment through treatment planning, the treatment...

Supervisor, Medical Records, Release Of Information Job Category: Health Information Management Requisition Number: SITES005637 Location: Augusta, GA 30912, USA Job Type: Full-Time Position Type: On-site Description Role: The Site Supervisor is responsible for managing the daily scheduling of the ROI Specialists at specific client site. The Site Supervisor will act as the liaison between MRO and Client Management staff to ensure that all ROI activities are compliant with established client policies, federal and state regulations and are completed in a timely manner. Tasks and Responsibilities: Manages workflow among on-site employees to ensure maximum productivity and quality standards are met. Adjusts work assignments as needed to cover peak periods, leave and vacancies. Prioritizes work to ensure completion of ROI function. Adjusts work assignments as needed to cover peak periods, leave and vacancies at the staffed hospital sites. Provides coverage in event of...

Health Information Management This position is in the Health Information Management section of the Health Administration Service at the Fargo Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Medical Records Technician (Coder-Outpatient and Inpatient) This position is in the Health Information Management (HIM) section of the Health Administration Service at the Fargo Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. This job is open to the public and internal to an agency. Open to current permanent Department of Veterans Affairs employees, current permanent Federal employees of other agencies and all US Citizens. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below. Duties This position requires the incumbent to physically report for work to the Fargo ND VAMC. Major duties include, but are not limited to, the following: Assigns codes to documented patient care encounters (inpatient and outpatient); encounters are routine and...

Compliance Specialist Responsible for all activities related to order compliance and management of physician data in system(s); this position assures optimal regulatory compliance. Essential Functions Monitor orders which are in escalation folder and perform necessary follow up. Provide education and support to Medical Records staff as it pertains to Mosia and indexing, to ensure timely and appropriate follow-up. Monitor reports and Mosia tracking features to assure goals of Orders Lifecycle are met. Perform follow up related to timely receipt of unsigned Orders including calls to physician offices and communication with Clinical team members/managers to resolve issues as needed. Elevate unresolved issues to Team Leader or Manager. Document actions in system to support compliance with internal policies and regulatory guidelines. Verify credentials including licensing, NPI, PECOS, OPRA, and OMIG/OIG/GSA sanctions, for new providers and update system accordingly. Monitor...

THE POSITION Start the next chapter of your nursing career with us! The Department of Human Services is seeking a dedicated and reliable Registered Nurse to provide exceptional managerial support as a Medical Records Examiner Supervisor to the Pittsburgh Field Operations team. At the Office of Long-Term Living, we work together as a dedicated team where collaboration and effective communication are integral. If you are excited to use your nursing expertise in a new and rewarding way, apply today! DESCRIPTION OF WORK In this position, you will oversee the Pittsburgh Nursing Facility Field Operations unit. Your work will involve performing reviews of clinical and fiscal records to ensure their compliance with state and federal requirements. You will review the records of skilled nursing facilities and Living Independence for the Elderly centers. Some of your duties will include ensuring consistent review and supervision, serving as a resource for staff, and evaluating care...

Medical Records Technician (Coder) This position is located in the Health Informatics Management Section (HIMS) of the Business Office at the Providence VA Medical Center. Responsibilities include performing a quality review of patient care documents and assigning codes specific for the type of care provided. Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnostic Related Group (DRG). Upon patient admission to the Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VISN VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA...

THE POSITION Are you a detail-oriented professional with an unwavering commitment to data integrity and patient privacy? The Department of Corrections (DOC), State Correctional Institution (SCI) at Laurel Highlands is looking for a Medical Records Supervisor. In this key role, you will bridge the gap between complex health care data and quality patient care, overseeing the systematic management of inmate health information within a secure environment. If you thrive in a high-stakes setting where accuracy is non-negotiable and your analytical skills can drive operation excellence, we invite you to bring your expertise to our dedicated Medical Records Department! DESCRIPTION OF WORK As a Medical Records Supervisor, you will oversee the operation of the Medical Records Department, where the medical histories of all inmates are established, classified, and maintained. This role involves supervising, planning, organizing, and performing technical work within the department....

Medical Records Technician (Coder) Auditor The Medical Records Technician (Coder) Auditor is located in the Health Information Management (HIM) section of Medical Administration Service at the VA Maryland Health Care System. A Medical Records Technician must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), the Healthcare Common Procedure Coding System (HCPCS) and be skilled in classifying medical data from patient health records. Duties include: Applying comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Reviewing assigned codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology...

Medical Records Technician (Coder) Auditor The Medical Records Technician (Coder) Auditor is located in the Health Information Management (HIM) section of Medical Administration Service at the VA Maryland Health Care System. A Medical Records Technician must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), the Healthcare Common Procedure Coding System (HCPCS) and be skilled in classifying medical data from patient health records. Responsibilities include: Applying comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Reviewing assigned codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural...