[Hiring] Medical Records Technician (Coder-Outpatient) @John D Dingell Department of Veterans Affairs Medical Center

Role Description

The John D. Dingell VA Medical Center in Detroit, Michigan is recruiting for a Medical Records Technician (MRT) (Coder-Outpatient) that will function in the Health Information Management (HIM) service. 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

• Assigns codes to documented patient care encounters covering the full range of health care services provided by the VA Medical Center (VAMC).
• Applies advanced knowledge of medical terminology, anatomy and 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.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.
• Applies codes based on 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.
• Performs a comprehensive review of patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure completed data capture.
• Assists 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.
• Reports incorrect documentation or codes in the electronic patient health record.
• Utilizes the facility computer system and software applications to correct code, abstract, record, and transmit data to the national VA database in Austin.

Qualifications

• 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 coding and to evaluate the adequacy of the documentation.
  • Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
  • Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity.

Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of 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.

Benefits

• This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces.
• Additional work schedules may become available at a future date.

Company Description

VA Healthcare System advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest.