[Hiring] Medical Records Technician - Coder Outpatient and Inpatient @Sheridan VA Health Care System

Role Description

This position is located in the Health Information Management (HIM) section at the Sheridan VA Medical Center. Medical Records Technician (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. Coding practitioners analyze and abstract patients health records and assign alpha-numeric codes for each diagnosis and procedure.

• Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC.
• Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and the principles and practices of health services.
• Selects and assigns codes from the current version of several coding systems including ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines, and conventions for ethical, accurate, and complete coding.
• Monitors regulatory and policy requirements affecting coded information.
• Performs comprehensive reviews of patient health records to abstract medical, surgical, ancillary, demographic, social, and administrative data.
• Assists facility staff with documentation requirements and provides technical support.
• Expertly searches patient health records to find documentation justifying code assignment.
• Utilizes facility computer systems and software applications for coding and data transmission.
• Uses various computer applications such as Outlook, Excel, Word, and Access.
• Orients and instructs new personnel and/or students on unit operations and coding.
• Works within a team environment, supports peers, and handles multiple tasks under pressure.
• Identifies principal diagnosis and procedure for every inpatient discharge.
• Conducts re-reviews of codes abstracted for patient encounters identified by the VERA committee.
• Codes inpatient professional fee services based on compliance with regulatory guidelines.
• Establishes primary and secondary diagnosis and procedure codes for outpatient encounters.
• Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system.
• Updates codes for current inpatient and Contract Nursing Home admissions.

Qualifications

• One year of creditable experience equivalent to the next lower grade level.
• Demonstrated Knowledge, Skills, and Abilities:
• Ability to analyze health records to identify pertinent diagnoses and procedures for coding.
• Ability to accurately perform the full scope of outpatient and inpatient coding.
• Skill in interpreting and adapting health information guidelines.
• Preferred candidates will have a minimum of three or more years of direct coding experience.
• Experience in billing is not considered "equivalent".
• Certification through AHIMA or AAPC is preferred.

Requirements

• Citizenship: Must be a citizen of the United States.
• English Language Proficiency: Must be proficient in spoken and written English.
• Experience: One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Education: Associate's degree in health information technology/management or related field.
• Completion of an AHIMA approved coding program or equivalent training.
• Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification.

Benefits

• Work Schedule: Monday-Friday, 7:30am-4:00pm.
• Telework: This position is designated as remote.
• Relocation/Recruitment Incentives: Not Authorized.
• Permanent Change of Station (PCS): Not Authorized.