• Perform prospective medical record reviews for clinical indicators • Review patient medical records for coding accuracy • Collaborate with healthcare providers and stakeholders • Participate in coding education for staff and maintain accuracy standards

Role Description This position is in the Health Information Management section at the Richard L. Roudebush VA Medical Center. MRTs (Coder) analyze, abstract, and classify medical data from patient health records across hospital and physician-based settings, including offices, group practices, multi-specialty clinics, and specialty centers. They assign ICD, CPT, and HCPCS codes and may also provide staff education on coding and documentation. Responsibilities - 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). - Upon patient admission to the Community Living Center/Nursing Home Care Unit, codes the admission diagnosis for use by unit staff. - All diagnoses and procedure codes are selected from the current version of the ICD coding system. - Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program. - 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 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. - Understands the nuances of the CPT coding system for Third Party Insurance cost recovery and accurately interprets instructional notations; bundles encounters when appropriate; uses established processes to communicate potential billing issues to Consolidated Patient Account Center (CPAC) staff. - Codes all identified surgical procedures; applies ICD and CPT coding guidelines and selects proper codes using the current code set and the encoder product suite; adds Anesthesia and Pathology codes for all billable surgical cases, which may involve creating the encounters. - Updates codes for current inpatient and Contract Nursing Home admissions for quarterly census and as directed for billable long stay (30+ days) admissions to reflect all patient conditions and care up to the census date or to the requested billing date. - May be required to review and enter coded data from paid Community Care claims using documentation (e.g., hard-copy claims) obtained from non-VA facilities. - May code diagnoses for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc. Work Schedule Monday - Friday. Employees are scheduled for an 8-hour working shift and may choose a start time anytime at or after 7:00 AM ET, provided their workday concludes no later than 5:00 PM ET. This position requires work to be performed within the Eastern Time Zone (ET) and adherence to a standard business-day schedule. All work, meetings, and collaborative activities must occur within these hours, and employees must remain available for work-related communications during this timeframe. Pay - Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off - 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 per year). Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. 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). Telework This position is currently authorized for telework - Location negotiable, incumbent must live within 50 mile radius of a VA Medical Center. To meet the Return to Office Executive Order requirements, selected candidates may be required to Return to Office. This will be discussed during the interview process. Virtual This position is currently designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Education Requirements 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. - Transcripts must be official or unofficial college transcripts. A copy of your certificate/degree or screenshot of your current classes are not a replacement of your transcript and they will not be used in the qualifying process. - Transcripts must include the following information: - Your Name - Name of the college or university - Full address of the college or university - Degree Received - Date Conferred Qualifications - United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - 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; OR, - 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 (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); 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. - 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. Grade Determinations - Medical Records Technician (Coder-Inpatient) GS-08: One year of creditable experience equivalent to the next lower grade level. Physical Requirements The work is primarily sedentary. Typically, the employee may sit comfortably to do the work. However, there may be some walking; standing; bending. No special physical demands are required to perform the work.

Role Description Reviews SDS and OBV records to identify the diagnosis and procedure codes performed during the patients stay are valid and in accordance with coding conventions and guidelines. Records types including same day surgery and observation encounter types. Works on routine assignments within defined parameters, established guidelines and precedents. Follows established procedures and receives daily instructions on work. Qualifications - High School Education/GED or equivalent: Required - Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred - Working knowledge of hospital Cerner EMR (electronic medical record): Required - Three years' coding and health care experience: Required - AHIMA Certified Coding Specialist (CCS): Required Requirements - Abstracts and assigns ICD-10-CM diagnosis codes and CPT procedure codes from the SDS and OBV patient record to ensure accurate APC assignment and to provide information required for reimbursement and statistical data submissions. - Validates appropriate dates of service against documentation in the EMR for SDS/OBV encounters. - Completes required abstract fields in registration conversation on SDS/OBV encounter for OSHPD and other data submissions. - Uses knowledge of modifier use to ensure accurate application on various payor types. - Communicates with appropriate departments related to charge corrections/modifications. - Audits medical records to ensure proper coding is completed and to ensure compliance with federal and state regulatory agencies. - Follows coding guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. - Reviews, understands and applies quarterly coding clinics, coding guidelines and coding conventions of ICD-10-CM references. - Collaborates to provide coding feedback and education to departmental leadership regarding completeness and accuracy of documentation and physician coding practices. - Analyzes content of reports and software edits to facilitate revisions with appropriate departments - NCCI edits. - Follows up coding holds, revenue cycle department holds including related and all other email communication. - Maintains required online Healthstream education courses. - Attends meetings and training pertaining to coder education, audit reviews, staff meetings, outpatient coder roundtable meetings, and SDC to OBV charges. - Performs other job-related duties as assigned. Benefits - Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. - Adventist Health participates in E-Verify. Visit E-Verify Participation and Right to Work notices for more information.

• Review and accurately code Trauma Surgery and E/M cases to maximize reimbursement in a timely manner • Review and accurately code E/M visits and office procedures • Able to work independently and research coding scenarios • Coder is responsible for meeting our daily production goal and our quality goal of averaging 95% accuracy rate on a consistent basis • Attend conference calls as necessary to provide information and/or feedback • Communicate with leadership on coding or documentation issues/trends • Stay current on all coding guidelines (to include surgery-specific guidelines) and maintain credentials as necessary • Participate in coding department and education meetings • Flexible to expand coding skill set into other specialties • Maintain confidentiality and protect sensitive information