USAJOBS · 3 hours ago
MED RECORDS TECHNICIAN (CODER)
Durham, North Carolina, USA
Full-time
Hybrid
Mid, Senior Level
$64K/yr - $64K/yr
1+ years expUSAJOBS is seeking a Medical Records Technician (Coder) for the Durham VA Medical Center. The role involves classifying medical data from patient health records and ensuring accurate documentation to support coding practices in various healthcare settings.
ConsultingGovernmentHuman ResourcesInformation TechnologyInternetStaffing Agency
No H1B
U.S. Citizen Only
Responsibilities
Responsible for reviewing the overall quality and completeness of clinical documentation
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 clinical documentation and provides education to clinical staff on inpatient episodes of care
Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding
Provides education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity
Adheres to accepted coding practices, guidelines and conventions to ensure ethical, accurate, and complete coding
Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator
Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs
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
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
Ensure 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
Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record
Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation
Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite
Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff
Ensures active intra-departmental training program is in place for the HIM staff
Determines and meets training needs of extra-departmental professional, para-professional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital
Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis
Identifies trends and/or opportunities to improve clinical documentation
Collaboratively works with the professional clinical staff and provides support and education on documentation issues
Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported
Qualification
Required
You must be a U.S. Citizen to apply for this job
Selective Service Registration is required for males born after 12/31/1959
Must be proficient in written and spoken English
Subject to background/security investigation
Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements
Must pass pre-employment physical evaluation
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP)
Complete all application requirements detailed in the 'Required Documents' section of this announcement
Citizenship. Citizen of the United States
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
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
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
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS
Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education
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 equivalent to the journey grade level of a MRT (Coder-inpatient)
An associate's degree or higher, and three years of experience in clinical documentation improvement
Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement
Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement
Employees at this level must have either a mastery level certification or a clinical documentation improvement certification
Knowledge of coding and documentation concepts, guidelines, and clinical terminology
Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record
Ability to collect and analyze data and present results in various formats
Ability to establish and maintain strong verbal and written communication with providers
Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines
Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS
Benefits
A career with the U.S. government provides employees with a comprehensive benefits package.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.
Company
USAJOBS
USAJOBS enables federal job seekers to access job opportunities across hundreds of federal agencies and organizations.
10001+ employees
Funding
Current Stage
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