Lead Medical Records Technician (Coder-Inpatient)
What you'd do
The Lead Medical Records Technician (Coder-Inpatient) performs the full scope of coding including assigning ICD-10-CM and ICD-10-PCS codes, abstracting records, chart analysis, peer review, and the review of diagnostic studies and procedures. The incumbent ensures accurate and complete coding. In addition, the lead supports the team by assisting with coding questions, providing coder education, and serving as a resource for complex cases to maintain coding quality and compliance.
Major duties
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 Gives on the job training to new coders and students to provide the individual with the basic knowledge, skill, and ability to perform the full range of routine and non-routine responsibilities required Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD-10-CM and PCS codes to ensure accurate data capture Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines Distributes and balances the workload among employees in accordance with established workflow or job specialization and assures timely accomplishment of the assigned workload 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 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 Trains others on the encoder product suite and utilizes this system on an ongoing basis to perform core coding duties and audits Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided Has constant interaction with health care providers, evaluating and communicating with the expectation on improving health record documentation, which will result in improved patient care and improved revenue generation Educates providers through feedback, email queries, or informal meetings Participates in the orientation of House Staff from affiliated medical schools and other personnel as needed 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 covering the full range of health care services 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 Applies 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 Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture Ensures 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 Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines Independently researches references to resolve any questionable code errors and contacts the supervisor as appropriate 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 Performs other duties as assigned Work Schedule: 7:30am - 4pm Recruitment/Relocation Incentive: Not Authorized Remote: This is a remote position.
What you need to qualify
Basic Requirements Citizenship. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy Experience and Education. (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records OR, (2) 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 (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, (3) 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. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. Certification: Employees at the GS-9 level must have a mastery level certification. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Grade Determination: GS-9: Experience. One year of creditable experience equivalent to the next lower grade level GS-8. Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Lead MRTs (Coder) must be able to perform all duties of a MRT (Coder). Lead MRTs (Coder) review coding and assist MRTs (Coder) in ensuring timeliness and improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate, prepare, and maintain various reports, and analyze data; and may also coordinate, assign, and monitor workflow. They provide input for performance evaluations and hiring. They orient and instruct new coding personnel and/or students on coding, abstracting, and use of the electronic health record and encoder software. They ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection. They monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs. They develop coding training materials and present a curriculum encompassing ongoing training initiatives. They provide assistance with coding inquiries from providers, MRTs (Coder), billers, and other facility staff. Lead MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Lead MRTs (Coder) may be at a facility or in a consolidated coding unit (CCU). Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (1) Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc. (2) Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. (3) Ability to effectively communicate, both orally and in writing, in order to meet program objectives. (4) Knowledge of training methods and the ability to provide training to new coding staff. (5) Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. (6) Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. Certification: Employees at this level must have a mastery level certification. Preferred Experience: Someone with the certification and experience, preferred experience is someone inpatient experience, leadership experience. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
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