Lead Medical Records Technician (Coder)

Department of Veterans Affairs

This position is located in the Health Information Management (HIM) section at the Loma Linda, CA 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.

• Duties include but are not limited to: 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. Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) Patient encounters are often complicated and complex requiring extensive coding expertise 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 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 Ensures provider documentation is complete and supports the diagnoses and procedures coded Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA databases Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies. Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources Identifies training needs of individuals based on productivity and accuracy reports, rejects from billing, and spot checks. Makes recommendations to Supervisor concerning disciplinary actions due to insufficient performance and identifies continuing education needs Has constant interaction with health care providers, evaluating and communicating with the expectation on improving health record documentation Other duties as assigned Work Schedule: Monday - Friday, 0730-1600 PST Compressed/Flexible: Not Available Telework: Available, as determined by the agency policy. Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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