Lead Medical Records Technician in United States

Summary The Cincinnati, OH VA Medical Center is recruiting for a full time Medical Records Technician-Lead Coder position. The Medical Record Technician/Lead Coder position is located under the Health Information Management (HIM) Section of Patient Business Service. Responsibilities Major Duties: This position is responsible for maintaining the quality of patient records, assigning appropriate International Classification of Diseases Clinical Modification (ICD-9-CM, ICD-10-CM, and ICD-10-PCS), Current Procedural Terminology (CPT-4), and Healthcare Common Procedure Coding System (HCPCS) codes, leading coders who perform the same tasks, and various other duties as assigned. The Lead Medical Records Technician (Coder) is skilled in classifying medical data from patient health records in hospital and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics and specialty centers. The incumbent analyzes and abstracts patients’ health records, and assign alpha-numeric codes for each diagnosis and procedure. Duties and Responsibilities include but are not limited to the following: 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. Reviews patient records and assigns diagnosis and procedure codes relating to admissions, operations, and procedures for each episode of hospitalization at the facility and public and private hospitals paid for by the facility. Preserves the integrity of the coding structure as set forth in ICD-9-CM, ICD-10-CM, ICD-10-PCS, DSM-IV, CPT-4,and HCPCS coding conventions, AMA guidelines and CMS regulations, AHA Coding Clinics, VHA Coding Guidelines, and VHA directives and handbooks, while adhering to guidelines for optimal reimbursement. Effectively utilizes resources to verify information and keep up to date on coding guidelines. Assigns codes to documented patient care encounters (inpatient and/or outpatient) 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. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. 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. Provides 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. Interacts 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. Ensures all documentation is present and in appropriate format, sequenced, identified and signed, meeting Joint Commission and VHA requirements. Completes Patient Treatment File (PTF) for each admission by abstracting pertinent information, including clinical and demographic information. Assists with the collection and reporting of data for documentation audits. Assists in the generation, assignment, and completion of census and other special surveys before closeout. Completes inpatient and professional fee coding on all inpatient charts (including Fee), and codes assigned outpatient encounters within time frames mandated in VHA directives. Participates in the orientation of House Staff from affiliated medical schools and other personnel as needed. Provides and assists in the performance of training, in-services and other educational activities regarding diagnosis and procedure code assignment, government regulatory requirements, and the use of encoder software. Develops training programs and materials and conducts continuing training responsibilities. The Incumbent in this position reports directly to Assistant Chief, HIM and must be able to work independently with minimal supervision. Work Schedule: Monday-Friday, 8:00 am-4:30 pm Virtual: This is a virtual position. Functional Statement #: 91160-O Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) – See “Additional Information” below for details. Qualifications BASIC REQUIREMENTS: 1. United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 2. English: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 3. Experience and Education 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, Education: An associate 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). TRANSCRIPTS REQUIRED. OR 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 Experience/ Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following experience and 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).TRANSCRIPTS REQUIRED. 4. Certification. Persons hired or reassigned to Lead MRT (Coder) positions must have a mastery level certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. Current mastery level certifications include: Certified Coding Specialist (CCS) Certified Coding Specialist – Physician-based (CCS-P) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Professional Coder (CPC) Certified Outpatient Coder (COC) Certified Inpatient Coder (CIC) GRADE DETERMINATIONS:IN ADDITION TO MEETING THE BASIC REQUIREMENTS LISTED ABOVE, YOU MUST MEET THE FOLLOWING GRADE REQUIREMENTS TO QUALIFY FOR THIS POSITION. For the GS-9, Lead Medical Records Technician (Coder) assignment you need to meet the below grade requirements: 1. Specialized Experience: One year of creditable experience equivalent to the journey grade level MRT (Coder), GS-8. 2. In addition to the experience above, the candidate must demonstrate all of the following Knowledge, Skills, and Abilities (KSAs): 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. 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. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. 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, which may include presenting reports to various organizational levels. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. 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).The applicant selected for this position must have a thorough working knowledge of ICD-9-CM, ICD-10- CM, ICD-10-PCS,DSM-IV-TR, HCPCS and CPT-4 coding classification systems, prospective payment methodologies including DRG’s and APC’s, medical and procedural terminology, anatomy and physiology, pharmacology, and pathophysiology in order to assign non-indexed medical terms/procedures to the appropriate area in the classification system. The employee must know when and where to look for symptoms and diagnoses and confirm if appropriate documentation exists in the record to justify assignment of a particular code. References: VA Handbook 5005/122, Part II, Appendix G57, Lead Medical Records Technician (Coder), Qualification Standards Physical Requirements: The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, records, or driving an automobile, etc. No special physical demands are required to perform the work. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. REMINDER: SF 50 – If you are a current Federal Government employee please be sure to upload your most current SF50 (dated in the year 2024) Reminder: This announcement is open to current permanent Patient Business Office Cincinnati VA Medical Center employees only . This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.