Role Description
We are seeking motivated and dependable Lead Medical Records Technician (Coder - Inpatient)! This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.
Responsibilities
• Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities.
• Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources.
• Reviews compliance monitors with Supervisor and identifies training needs.
• Reviews, audits, trains, monitors, and completes special assignments within specified time frames.
• Required to train others on the encoder product suite.
• Utilizes this system on an ongoing basis to perform core coding duties and audits.
• Has constant interaction with health care providers evaluating and communicating with the expectation on improving health record documentation.
• Identifies the principal diagnosis and principal procedure for every inpatient discharge.
• Codes the admission diagnosis for use by unit staff upon patient admission to the Community Living Center/Nursing Home Care Unit.
• Conducts re-reviews of codes abstracted for patient encounters identified by the VERA committee.
• Codes inpatient professional fee services for identified inpatient admissions.
• Trains and works closely with professional and administrative staff to assist in the development, maintenance, and usage of ICD and PCS codes.
• Conforms to standards and participates in the technical evaluation and validation of health records for compliance.
• Distributes and balances the workload among employees in accordance with established workflow or job specialization.
Qualifications
• 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 (ROI) must be proficient in spoken and written English.
• 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.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements.
Requirements
• Persons hired or reassigned to MRT (Coder) positions must have either Apprentice/Associate Level Certification through AHIMA or AAPC, Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• One year of creditable experience equivalent to the journey grade level MRT (Coder).
• Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities.
• Advanced knowledge of current coding classification systems for the subspecialty assigned.
• Ability to effectively communicate, both orally and in writing.
• Knowledge of training methods and the ability to provide training to new coding staff.
• Ability to collect and analyze data and present results in various formats.
• Leadership skills, including interpersonal relations and conflict resolution.
Benefits
• Work Schedule: Monday - Friday, 8:00 AM - 4:30 PM EST.
• Pay: Competitive salary and regular salary increases.
• Parental Leave: Up to 12 weeks of paid parental leave after 12 months of employment.
• Paid Time Off: 37-50 days of annual paid time off per year.
• Child Care Subsidy: Eligible for a childcare subsidy up to 25% of total eligible childcare costs.
• Retirement: Traditional federal pension and federal 401K with up to 5% contributions by VA.
• Insurance: Federal health/vision/dental/term life/long-term care insurance options.
• Telework: Currently authorized for telework; location negotiable.
• Remote/Virtual: Designated as remote; full-time employment conducted outside of a VA facility.