Medical Records Technician (Coder-Outpatient)

This position is located in the Health Information Management (HIM) section at the Beckley 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.

These coding practitioners analyze and abstract patients' health records and assign alphanumeric codes for each diagnosis and procedure.

FUNCTIONS: * 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.

* Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS.

Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) 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 as well as the principles and practices of health services and the organizational structure to ensure proper code selection.

* Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) 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.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

* Performs a comprehensive review of the electronic 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; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

* Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the electronic health record.

* Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases.

* Uses a variety of computer applications in day-to-day activities and duties, such as Microsoft Outlook, Excel, Word, and Teams; competent in use of electronic health record applications as well as the encoder product suite.

* Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.

* Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement.

* Establishes the primary and secondary diagnosis and procedure codes for outpatient professional and technical fee encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided.

Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; uses established processes to communicate potential billing issues to Consolidated Patient Account Center (CPAC) staff.

Work Schedule: Monday - Friday, 8:00 am - 4:30 pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases.

When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.

Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not Available.

Functional Statement #: 517-26371-F Permanent Change of Station (PCS): Not Authorized