• responsible for reviewing and analyzing documentation present in the medical record for inpatient, outpatient and/or professional services to assign diagnoses/procedure codes as described by the physician(s) of record • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines

• Analyzes relevant clinical and demographic information from the Health Information record • Assigns appropriate ICD-10 and CPT codes following appropriate guidelines • Ascertains compliance with CMS, state and other regulatory agencies • Provides mentorship and training to onboarding coders • Completes analysis of documentation and code assignment according to the American Hospital Association Official ICD-10 Coding Guidelines • Performs queries and obtains documentation required for coding • Maintains communication with Management and Providers to ensure timely notification of identified documentation issues

• Responsible for accurately and timely coding of moderately complex encounters following established coding, CMS regulations and hospital guidelines. • Accurately codes diagnostic and procedural information following official coding guidelines, facility specific guidelines and federal regulations. • Reviews moderately complex medical records to identify sequence, code diagnoses and procedures according to established coding, CMS and hospital guidelines. • Responsible for accurately coding hospital same day surgery, observations, ancillary, ED encounters and/or professional services. • Ensures optimal CPT, ASC, APC, APG assignment as applicable. • Understanding and ability to resolve coding specific edits such as CCI, LCD, NCD, and MUE. • Supports OP Clinical Documentation Improvement program. • Maintains productivity and quality rate according to established standards. • Works within UH Billing time frames. • Maintains coding knowledge and skills via written coding resources, clinical information and educational webinars. • Maintains knowledge of guidelines and regulations affecting the UHHS Coding Department. • Maintains up to date credentials. • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).

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, and procedures 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 for ethical, accurate, and complete coding. - Monitors 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 patient care provided. - Expertly searches the patient health record to find documentation justifying code assignment. - Utilizes the facility computer system and software applications to 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. Qualifications - United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - Proficient in spoken and written English. - One year of creditable experience equivalent to the next lower grade level. - Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC. - Must maintain required certification through continuing education. Requirements - Experience: One year of creditable experience equivalent to the next lower grade level. - Demonstrated Knowledge, Skills, and Abilities: - Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding. - Ability to accurately perform the full scope of outpatient and inpatient coding. - Skill in interpreting and adapting health information guidelines. Benefits - Competitive salary and regular salary increases. - 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays). - Up to 12 weeks of paid parental leave after 12 months of employment.