Role Description This position is in the Health Information Management Section at the VA Northern California Health Care System. Certified Coders classify medical data from patient health records. Seeking candidates with robust inpatient coding experience for a complex, multi-specialty Acute Care Hospital. Expertise in ICU coding, psychiatric inpatient admissions, complex surgical procedures using ICD10-PCS and DRG assignment is required. Experience in high volume, tertiary, or academic hospitals is preferred. Responsibilities - Select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for inpatient facility and/or professional services. - Comprehensive review of inpatient documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures using ICD-PCS for accurate assignment of diagnosis-related groups (DRG), and/or assigning CPT/HCPCS codes for inpatient professional services. - Independently review and abstract clinical data from the inpatient record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes. - Code all complicated and complex medical/specialty disease processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties. - Consult directly with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record. - Abstract, assign, and sequence codes into the encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered. - Query clinical staff with documentation requirements to support the coding process. - Enter and correct information that has been rejected; correct any identified data errors or inconsistencies. - Maintain a 95% coding accuracy on quality audits. Ensure audit findings have been corrected and refiled. - Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record. - Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. - Adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate diagnosis, operation, procedure, or ancillary code. - Use various required computer applications to abstract records, assign codes, and record and transmit data. Work Schedule: Monday - Friday, 8:00am - 4:30pm PST Telework: Not Available Virtual: This position is Remote 100% Functional Statement #: 07110F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Qualifications - Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. - Basic Requirements: - United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. - OR Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management. - OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. - OR Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. Requirements - Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either: - Apprentice/Associate Level Certification through AHIMA or AAPC. - Mastery Level Certification through AHIMA or AAPC. - Clinical Documentation Improvement Certification through AHIMA or ACDIS. - Grandfathering Provision: All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held. Grade Determinations - Medical Records Technician (Coder-Inpatient), GS-8 - Experience: One year of creditable experience equivalent to the next lower grade level. - Demonstrated Knowledge, Skills, and Abilities: - Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding. - Ability to accurately perform the full scope of inpatient coding. - Skill in interpreting and adapting health information guidelines. Physical Requirements VA Directive and Handbook 5019, Employee Occupational Health Service.

Role Description In the team that delivers a Healthier Bottom Line, the Hospital Biller I is a Full Time, Regular position working in several hospital client EMRs such as Epic, Cerner, and Meditech Expanse. This position is remote Monday-Friday day shift 8am-5pm PST. - Responsible for all phases of billing to government and commercial insurers, including initial billing of clean claims electronically or on paper. - Subsequent follow-up on unpaid claims to the point of payment or resolution of the claim, and resolving credit balances. - Prioritizes assigned worklist of aged accounts appropriately and works on aging accounts to their resolution. - Reviews and processes electronic claims, claim edits, and deletions appropriately and compliantly. - Interprets billing regulations accurately and within federal, state, and third-party billing regulations and policies. - Utilizes various client host systems in order to research and rebill claims. - Other special projects and duties as assigned. Qualifications - Education: High School Diploma/GED required; Two-year medical billing course successful completion is desired. - Experience: At least one year of experience in billing medical claims to either government or commercial insurers; at least one-year prior experience in Epic billing software; preferably has experience in hospital billing. - Working knowledge of government hospital payment methodologies including OPPS, Critical Access Hospital method II, or both preferred. - CPT, HCPCs, and ICD-10 coding experience preferred. - Experience with electronic claims scrubbing and clearinghouse systems preferred. - Computer Skills: Experience with Epic software required; Microsoft Office products (Outlook, Word, Excel), Internet, Intranet, Meditech or other hospital or physician EHR/accounting system. - Remote Work Capability: Ability to work from a remote (home) based environment if requested. Requirements - Must be able to pass a background check required by RCW 43.43.830-840 to work with children under the age of 16, developmentally disabled persons, or vulnerable adults. - Must be able to pass a post-offer, pre-employment drug test. Benefits - Attendance is a requirement for this position. - Rotates to other shifts and locations as needed.

Role Description The Medical Coder is responsible for all coding functions for Omega Hospital, including professional and technical services across surgical and pre-operative encounters. This role supports accurate, compliant, and optimized reimbursement by ensuring complete and precise coding for hospital services, anesthesia, first assist, and related professional components. This is a remote, in-house position requiring close collaboration with physicians, anesthesia providers, scheduling, and the billing team. The coder will also support coding audits, denials, and appeals, and play a key role in maintaining compliance while optimizing revenue integrity. Estimated surgical volume is approximately 250 cases per month. Essential Duties & Responsibilities - Coding & Documentation - Perform complete coding for all Omega Hospital services, including: - Hospital (technical/facility) components - Professional services, including Anesthesia and First Assist - Pre-operative and related encounters - Assign accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes in accordance with: - AMA, CMS, and payer-specific guidelines - Federal and state regulations - Omega Hospital compliance policies - Review operative reports, physician documentation, and clinical records to ensure coding accuracy, completeness, and appropriate specificity. - Systems & Workflow - Perform all coding activities within CPSI and related billing software platforms. - Utilize Omega Hospital-provided equipment (computer and related tools). - Work closely with: - Surgeons and proceduralists - Anesthesia providers - Scheduling staff - Billing and revenue cycle teams to resolve documentation gaps, clarify procedures, and ensure timely claim submission. - Revenue Integrity, Audits & Appeals - Participate in and support internal and external coding audits. - Assist with coding-related denials, appeals, and payer inquiries. - Identify documentation or coding trends that may impact compliance or reimbursement and proactively communicate findings to leadership. - Support process improvements to enhance accuracy, efficiency, and compliance. - Compliance & Confidentiality - Maintain strict adherence to HIPAA, Joint Commission standards, and Omega Hospital compliance policies. - Protect the confidentiality and security of all patient health information. - Stay current on coding updates, regulatory changes, and payer guidance relevant to surgical hospitals and anesthesia services. - Professional Expectations - Demonstrate strong communication skills, responsiveness, and accountability in a remote environment. - Maintain consistent availability to meet workflow demands and collaborate effectively with internal teams. - Exhibit a high level of professionalism, attention to detail, and work ethic. Patient Population Served This is a non-clinical position serving the general patient population through accurate documentation and coding of healthcare services. Qualifications - High school diploma or equivalent. - Formal training or certification in medical coding (CPC, CCS, or equivalent experience). - Minimum 2 years of hands-on medical coding experience, preferably including: - Surgical services - Inpatient and outpatient hospital coding - Anesthesia and/or professional fee coding - Ability to work independently in a remote setting while meeting deadlines and productivity expectations. - Successful completion of pre-employment background screening requirements. Preferred Qualifications - Coding certification (CPC, CCS, CCS-P, or equivalent). - Experience with CPSI or similar hospital information systems. - Experience in a surgical hospital or ASC environment. - Familiarity with coding audits, appeals, and payer compliance. Physical Demands & Work Environment - Remote office environment. - Prolonged periods of computer use. - Occasional flexibility in schedule may be required to support operational needs. ADA & Corporate Compliance Omega Hospital complies with the Americans with Disabilities Act (ADA) and provides reasonable accommodations where required. Employees are expected to adhere to all Omega Hospital compliance policies, Code of Conduct, and confidentiality requirements.

Role Description Advanced coding position that requires review of medical record documentation and accurately assigns ICD-10-CM, ICD-10 PCS, CPT IV codes, as well as assignment of the Medicare Severity Diagnosis Related Group (MS-DRG) / All Patient Refined - Diagnosis Related Group (APR-DRG) based on payor classification and abstracts specific data elements for each case in compliance with federal regulations. This position codes all types of inpatient records and follows the Official Guidelines of Coding and Reporting, the American Health Information Management Association (AHIMA) Coding Ethics, as well as all American Hospital Association (AHA) Coding Clinics, CMS directives and bulletins, Fiscal intermediary communications. Utilizes 3M 360 in accordance with established workflow. Follows Ensemble policies and procedures and maintains required quality and productivity standards. - Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnoses and procedure codes. - Responsible for verification of the patient's discharge disposition and ensures appropriate present on admission (POA) indicators are assigned to each code. - Correctly abstracts required data per facility specifications. - Assists with writing appeals for Diagnosis Related Group (DRG) denials. - Monitors and works on accounts that are Discharged Not Final Billed, failed claims, stop bills, and epremis. - Collaborates with Clinical Documentation Specialists (CDEs) and members of the medical staff to ensure completeness of documentation. - Ensures accuracy and maintains established quality, productivity standards, and key performance indicators for 3M 360 CAC for CRS and Direct Code. - Remains abreast of current Centers for Medicare and Medicaid Services (CMS) requirements. - Maintains competency and accuracy while utilizing tools of the trade, such as the 3M encoder, Computer Assisted Coding (CAC), Clinical Documentation Improvement System (CDIS), and abstracting systems. Qualifications - Required Licensure: RHIA, RHIT, CCS, CIC, or CCA Benefits - Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible) - Medical, dental, vision, prescription coverage, HAS/FSA options, life insurance, mental health resources and discounts - Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders - Tuition assistance, professional development and continuing education support