Northern Indiana HCS

Role Description This position is in the Health Information Management Section (HIMS) of Health Administration Service (HAS) at the VA Northern Indiana Health Care System (NIHCS). 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. Responsibilities - 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). - 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 (inpatient and outpatient); encounters are routine and less complex or for only one specialty or subspecialty. - 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. - Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. - Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. - Uses knowledge of the organization and structure of the electronic health record to capture and justify code assignment. - Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA databases. - Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. - Identifies the principal diagnosis and principal procedure for every inpatient discharge for one specialty or subspecialty and/or for short stay and/or less complex inpatient stays; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). - Codes inpatient professional fee services for identified inpatient admissions. Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA specific guidance for optimum allowable reimbursement. - Establishes the primary and secondary diagnosis and procedure codes for outpatient professional and technical fee encounters for one specialty or subspecialty following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of E/M service provided. - Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census for assigned inpatient admissions; updates any assigned billable long stay (30+ days) admissions to reflect all patient conditions and care up to the census date or to the requested billing date. 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: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). - Certification: - Apprentice/Associate Level Certification through AHIMA or AAPC. - Mastery Level Certification through AHIMA or AAPC. - Clinical Documentation Improvement Certification through AHIMA or ACDIS. - 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. - Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. Requirements - Work Schedule: Monday - Friday, 8:00 AM - 4:30 PM - Recruitment Incentive (Sign-on Bonus): Not Authorized - Permanent Change of Station (Relocation Assistance): Not Authorized - Pay: Competitive salary and regular salary increases - Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) - Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. - Child Care Subsidy: After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. - Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA - Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) - Remote: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. - Functional Statement #: 91374A - Permanent Change of Station (PCS): Not Authorized - Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service Benefits - Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.