[Hiring] Medical Records Technician (Coder) Auditor @Royal C Johnson Veterans Memorial Hospital

Role Description

This position is located in the Health Information Management (HIM) section at the Sioux Falls VA Medical Center. MRTs (Coder) 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:

• Temporarily eligible for Remote work within 50 miles of a VA Medical Center.
• May fall under the Presidential Memorandum titled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review.
• Announcement will close once 50 applicants are reached.
• Duties may include but are not limited to the following:
• Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.
• Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Apply 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 ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines and conventions when validating the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Applies guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
• Reviews, analyzes and reports performance monitors for inpatient, outpatient, VERA and Non-VA Medical Care (purchased care) coding.
• Reviews coding and assists coders in improving coding accuracy.
• Provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations.
• Facilitates improved overall quality, completeness, and accuracy of coded data.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
• As a technical expert in health information coding matters, provides advice and guidance on documentation and coding requirements.
• Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines, audit standards, and results in appropriate data capture and reimbursement.
• Analyzes audit results and prepares summary feedback for individual coders and/or clinicians, making recommendations for improvement.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices.

Qualifications

• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• 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.
• 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.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC.

Requirements

• Proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation.

Benefits

• Not Authorized for Relocation/Recruitment Incentives.
• Not Authorized for Permanent Change of Station (PCS).