Role Description The VISN 19 Consolidated Coding Unit (CCU) Medical Record Technician (MRT) is located within the Business Office Support Services (BOSS), Health Information Management (HIM) section, within VISN 19, Rocky Mountain VA Network. - Assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC. - Patient encounters are often complicated and complex requiring extensive coding expertise. - 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. - Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). - Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. - Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program. - 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 to ensure complete data capture. - Profiles the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs. - Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. - Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. - Ensures provider documentation is complete and supports the diagnoses and procedures coded. - 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. - Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. - 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. - Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG). - Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program. - Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite. - Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Qualifications - English Language Proficiency: Per VA Handbook 5005, Part II, Chapter 3, Section A, Paragraph 3j. - 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. - Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. - Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification through AHIMA or AAPC, Mastery Level Certification through AHIMA or AAPC, Clinical Documentation Improvement Certification through AHIMA or ACDIS. Requirements - GS-4 Experience and/or Education: None needed beyond Basic Requirements. - GS-5 Experience and/or Education: One year of creditable experience equivalent to the next lower grade level (GS-4) OR successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education. - GS-6 Experience: One year of creditable experience equivalent to the next lower grade level (GS-5). - GS-7 Experience: One year of creditable experience equivalent to the next lower grade level (GS-6). - GS-8 Experience: One year of creditable experience equivalent to the next lower grade level (GS-7). Benefits - Work Schedule: Monday - Friday, 8:00am - 4:30pm. Hours are flexible with various tours available. - Remote: Yes. Remote exempted positions are reviewed annually and do not imply permanent remote work status. - Relocation/Recruitment Incentives: Not authorized. - Permanent Change of Station (PCS): Not authorized. - Financial Disclosure Report: Not required.

• Utilize available encoder, grouper software, and other coding resources to determine the appropriate ICD-10-CM, CPT, and/or HCPCS including specialty specific codes and Evaluation and Management (E&M) codes • Maintain an understanding and apply knowledge of National Correct Coding Initiatives (NCCI), Local Coverage Documents and National Coverage Documents (LCD/NCD) directives, Medically Unlikely Edits (MUEs), and Medicare Teaching Physician Guidelines, applying knowledge of applicable regulatory requirements and institutional guidelines to select appropriate codes and modifiers

Role Description Under limited supervision, the Coder ER reviews medical records and performs coding on all diagnoses, procedures, DRG/APC and charge codes. The Coder ER uses the most accurate codes for reimbursement purposes, research, epidemiology, statistical analysis outcomes, financial and strategic planning, evaluation of quality of care, and communication to support the patient’s treatment. The Coder ER will be charged with maintaining the confidentiality of patient records and procedures. - Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records. - Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. - Utilizes technical coding principles and DRG/APC reimbursement expertise to assign appropriate codes. - Abstracts and codes pertinent medical data into multiple software programs and/or encoders. Follows official coding guidelines to review and analyze health records. - Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. - Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents. - Identifies codes for reporting medical services, procedures performed by physicians. - Enters codes into various computer systems dependent upon the various clients. - Track and document productivity in specified systems, maintain productivity levels as defined by the client. - Maintain 95% quality rating. - Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. Qualifications - Ability to prioritize and multi-task in a fast-paced, changing environment. - Demonstrate ability to work in all work types and specialties. - Demonstrate ability to self-motivate, set goals, and meet deadlines. - Demonstrate leadership, mentoring, and interpersonal skills. - Demonstrate excellent presentation, verbal and written communication skills. - Ability to develop and maintain relationships with key business partners by building personal credibility and trust. - Maintain courteous and professional working relationships with employees at all levels of the organization. - Demonstrate excellent analytical, critical thinking and problem solving skills. - Skill in operating a personal computer and utilizing a variety of software applications. - Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes. - Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation. Requirements - This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. - This position occasionally requires long hours and weekend work. - Minimal travel required; up to 5%. - Successful completion of an AAPC or AHIMA-approved Coding Certificate Program and a minimum of two to four years of current production coding experience in both acute care and pro fee. - Must have the following certificates and/or licenses: CPC, COC, RHIA, RHIT, CCS, and/or CCS-P. Benefits - Omega is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status. Company Description Founded in 2003, Omega Healthcare Management Services® (Omega Healthcare) empowers healthcare to thrive via intelligent solutions that optimize revenue cycle operations, administrative workflows, care coordination, and clinical research on a global scale. The company works with providers, payers, life science companies, medical device manufacturers, health technology firms, researchers, and industry partners to amplify teams with robust technology, specialty expertise, and operational support. Omega Healthcare serves more than 350 healthcare organizations with 35,000 skilled workers in the United States, India, Colombia, and the Philippines.

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