[Hiring] Supervisory Medical Records Technician @Edward Hines Junior Hospital

Role Description

This position is located in the Health Information Management (HIM) section at the Edward Hines Jr. VA Hospital. 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.

• Coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.
• Applies 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.
• 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 accepted 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.
• 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 the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Insures provider documentation is complete and supports the diagnoses and procedures coded.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Reports incorrect documentation or codes in the electronic patient health record.
• Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access.
• Ensures current versions of all software applications are loaded and functional after any updates or changes.
• Works within a team environment; supports staff in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
• Develops performance standards and conducts performance evaluations for subordinate staff.
• Schedules the sequence of work and operations on a weekly, monthly and quarterly basis to assure even workflow and distribution.
• Prepares workload and production reports; reports on operations and problems encountered; and presents proposed requests for resource needs based on past experience.
• Coordinates with other Service representatives on matters concerning health record documentation and coding.
• Keeps abreast of all regulations and guidelines governing the coding section, ensuring that staff supervised is educated as needed.
• Other duties as assigned.

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Experience and Education: Must meet one of the following:
  • 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.
  • Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
• Certification: Persons hired or reassigned to the Supervisory MRT (Coder) positions 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.

Requirements

• Experience equivalent to the next lower grade level GS-9.
• Mastery level certification required for all positions above the journey level.
• Supervisory MRTs (Coder) are responsible for supervising coding staff at the facility level.
• Responsible for program management of a coding section/unit to ensure performance monitors are established and met.
• Performs a full range of supervisory responsibilities, including evaluating performance and resolving employee complaints.
• Collaborates with revenue, compliance, and other departments to support coding accuracy.
• Provides education to clinical and coding staff.

Benefits

• Work Schedule: Monday - Friday, 7:30am - 4:00pm. Tour of Duty varies based on the needs of the service.
• Telework: Remote.
• Relocation/Recruitment Incentives: Not Authorized.