[Hiring] Medical Records Technician (CDIS - Inpatient) @John L McClellan Memorial Veterans' Hospital

Role Description

MRTs (CDIS - 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. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Responsibilities

• Demonstrates expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).
• Reviews the overall quality and completeness of clinical documentation.
• Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.
• Reviews clinical documentation and provides education to clinical staff on outpatient episodes of care.
• Prepares and conducts provider education on documentation processes in the health record.
• Provides education to providers on the need for accurate and complete documentation in the health record.
• Assists facility staff with documentation requirements to accurately reflect patient care.
• Consults with professional staff for clarification of conflicting or ambiguous clinical data.
• Adheres to accepted coding practices, guidelines, and conventions.
• Monitors ever-changing regulatory and policy requirements affecting coded information.
• Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation.
• Develops and conducts seminars, workshops, short courses, and informational briefings.
• Facilitates improved overall quality, completeness, and accuracy of health record documentation.
• Participates in clinical rounds and may offer information on documentation, coding rules, and reimbursement issues.
• Maintains statistical database(s) to track results and validate the program.

Work Schedule

Monday - Friday, 8:00 am to 4:30 pm, subject to change based on the needs of the facility.

Benefits

• Competitive salary and regular salary increases.
• 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays).
• Parental Leave: Up to 12 weeks of paid parental leave after 12 months of employment.
• Child Care Subsidy: Eligible for childcare subsidy up to 25% of total eligible childcare costs.
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% contributions by VA.
• Insurance: Federal health/vision/dental/term life/long-term care insurance.
• Remote work eligible and exempted from returned to office requirements.

Qualifications

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology.
• Ability to collect and analyze data and present results in various formats.
• Ability to establish and maintain strong verbal and written communication with providers.
• Knowledge of regulations that define healthcare documentation requirements.
• Extensive knowledge of coding rules and regulations, including current clinical classification systems.
• Knowledge of severity of illness, risk of mortality, and complexity of care.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education.

Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English.
• Experience: One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Education: Associate's degree from an accredited college or university in health information technology or related field.
• Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification.

Physical Requirements

Physical aspects associated with work required of this assignment are typical for the occupation, may require standing, lifting, carrying, sitting, stooping, bending, pulling, and pushing.

Work Environment

Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions.