Role Description This position is located in the Health Information Management (HIM) section at the William S. Middleton Memorial VA Hospital. 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure. Responsibilities - Assigns codes to documented patient care encounters (inpatient and 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, and the principles and practices of health services to ensure proper code selection. - Selects and assigns codes from the current version of several coding systems, including ICD, CPT, and/or HCPCS. - Adheres to accepted coding practices, guidelines, and conventions 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 patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data. - Assists facility staff with documentation requirements to accurately reflect the patient care provided. - Consults with professional staff for clarification of conflicting or ambiguous clinical data. - Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database. - Orients and instructs new personnel and/or students on unit operations, coding, abstracting, and use of an electronic health record. - Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks. Qualifications - Skill in applying current coding classifications to a variety of inpatient and outpatient specialty care areas. - Ability to communicate with clinical staff for specific coding and documentation issues. - Ability to research and solve coding and documentation related issues. - Skill in reviewing and correcting system or processing errors. - Ability to abstract, assign, and sequence codes, including complication or comorbidity/major complication or comorbidity (CC/MCC), and POA indicators. Requirements - United States Citizenship. - Proficient in spoken and written English. - One year of creditable experience equivalent to the next lower grade level. - Certification through AHIMA or AAPC. - Maintaining required certification through continuing education. Benefits - 100% remote position. - Work Schedule: 8:00am-4:30pm.

Role Description We are looking for a motivated, experienced Profee Coder | Physician Practice Complex Coder with 3+ years of Cardiology Complex Coding experience (ideally Surgical Cardiology) to join our talented team. This position does require Certified Professional Coder (CPC) in active status (this position requires more than an apprentice CPC-A) with recent/consistent coding work history of 3 years or more. - Evaluates medical records and provides clinical and surgical abstraction for a full range of complex and/or multispecialty surgical, procedural, and E&M professional services in accordance with nationally recognized coding guidelines. - Utilizes coding knowledge and expertise to support department projects, validation edits, and/or revisions. Qualifications - 3 years recent experience in Surgical Cardiology Profee EM coding (clearly reflected in your attached resume). - Specialty Cardiology coding experience preferred. - Must be currently certified through AAPC or AHIMA, as defined in minimum qualifications below. - This is a COMPLEX role, requiring more than a CPC-A level certification. Requirements - High school diploma/GED or equivalent working knowledge and specialized formal training equivalent to the two-year certification course in medical record keeping principles and practices. - Requires at least one of the following certifications in active status: - Certified Professional Coder (CPC) - Certified Coding Specialist (CCS) - Certified Coding Specialist – Physician (CCS-P) - Registered Health Information Administrator (RHIA) - Registered Health Information Technician (RHIT) - Requires three or more years of complex professional coding experience within specialty. - Must demonstrate knowledge and understanding of ICD and CPT coding principles. - Must be able to work effectively and efficiently in a remote setting, utilizing common office programs, coding software, and abstracting systems. Benefits - Flexible scheduling after training completed. - Fully remote position available in specified states. - Opportunity to apply unique experience and expertise in support of a nationally-recognized healthcare leader.

• Review medical record documentation to abstract and assign diagnoses, procedures, and modifiers • Provide feedback regarding documentation and coding issues • Maintain understanding of and ensure compliance with all applicable Official Coding Guidelines • Participate in coder and provider education including documentation improvement efforts for providers • Interact with provider, nursing staff and departments as assigned • Assist in the training and quality assurance of all coding levels • Strive for strong unit cohesion by working well with other members of the team

• Assigns ICD-10-CM, CPT, and HCPCS Level II codes to completed and signed medical documentation creating an appropriate assigned medical claim. • Abstracts specified data and information from patient records in order to determine appropriate modifiers for claim submission. • Queries providers for clarification of documentation when unclear or inadequate in order to code accurately. • Requests providers to complete addendums as necessary. • Stays up-to-date with ICD-10-CM, CPT, HCPCS Level II, AMA, CMS and other federal, state, local, and Phelps Health-specific coding guidelines, rules, and regulations and applies those guidelines to all types of patient accounts. • Abides by AAPC’s “Standards of Ethical Coding” and Phelps Health’s Corporate Compliance coding guidelines. • Monitors providers documentation for timely completion. • Notifies Coding Manager of any providers who fall outside the designated 73-hour turnaround time frame. • Maintains the designated 3 business day time frame for coding completed records and provides weekly report summaries to Coding Manager. • Maintain productivity standards as set forth by Phelps Health productivity matrix. • Maintain annual certification through AAPC or AHIMA and completes required CEUs for certification maintenance.