Role Description This position is located in the Health Information Management (HIM) section at the Chillicothe VA Medical Center. 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 - Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS. - 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 electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. - 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. - Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Teams. - Provides daily operational oversight of all coding functions to ensure needs are met by adjusting staffing, investigating workflow issues, answering coder questions, ensuring turnaround times are maintained, developing action plans, and following appropriate escalations. - Develops performance standards and conducts performance evaluations for subordinate staff. Identifies, communicates, and ensures coding staff meet productivity and accuracy standards. - Schedules the sequence of work and operations on a weekly, monthly, and quarterly basis to assure even workflow and distribution, expeditious handling of priorities and the meeting of deadlines. Work Schedule Monday through Friday, 7:30 a.m. to 4:00 p.m. Pay Competitive salary and regular salary increases. 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). 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. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. Applicants must live within 50 miles of one of our facilities as they may be subject to the RTO order. Virtual This is not a virtual position. 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. - 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. - Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. - Certification: Apprentice/Associate Level Certification through AHIMA or AAPC, or Mastery Level Certification through AHIMA or AAPC. Grade Determinations - Certification: You must have a Mastery Level Certification through AHIMA or AAPC. - To qualify for GS-10: You must have one year of creditable experience equivalent to the GS-9 grade level of a MRT (Coder). - Ability to perform a full range of supervisory duties, including recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work. - Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS. - Ability to provide or coordinate staff development and training. - Leadership and managerial skills, including skill in interpersonal relations and conflict resolution. - Ability to collect and analyze data, identify trends, and present results in various formats. Preferred Experience - Previous supervisory experience. - Experienced in medical coding. Physical Requirements The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, small parts; or driving an automobile, etc. No special physical demands are required to perform the work.

• Review clinical documentation and assign accurate codes using ICD-10-CM, ICD-10-PCS, and CPT systems • Abstract key data elements for reporting to CMS, HSCRC, and other regulatory agencies • Code outpatient and recurring accounts across multiple service lines, including JMC-JMC/R, BHS, and Outpatient Rehab • Ensure coding quality supports internal and external reporting, billing, and analytics

Role Description Performs complex retrospective analysis of medical record documentation to identify coding and billing errors and inconsistencies according to guidelines of the AHA, CMS, AMA, Clinic Coding Clinic and CPT Assistant. - Analyzes audit findings to identify potential root causes of coding errors and prevent their reoccurrence. - Provides second-level review of diagnosis, procedure and billing codes to ensure compliance with legal and procedural policies that ensure optimal reimbursements while adhering to regulations prohibiting unbundling and other questionable practices. - Researches, analyzes and responds to inquiries regarding compliance, inappropriate coding, denials and billable services. - Provides technical support and feedback training to internal coding staff regarding coding compliance, documentation, regulatory provisions, third party payer requirements, medical necessity requirements. - Protects the privacy and confidentiality of patient health and client information. - Follows the Standards of Ethical Coding as set forth by AHIMA and adheres to official coding guidelines and compliance practices. - Suggests physician query opportunities based on documentation and clinical needs. - Prepares deliverables for the coders as required. - Reports work time and work productions in a timely and accurate manner. - Communicates with coworkers in an open and respectful manner which promotes teamwork and knowledge sharing. - Provides schedule of planned work activities, events and sites, and any changes to management and appropriate staff. - Maintains professional coding credentials and knowledge of coding, reimbursement methodologies and compliance issues through education. - Monitors the ongoing progress and success of each coder. - Maintains QA percentages within two internal quality goals: - Overall minimum coder accuracy of 95% - QA review percentages as close to 10% as possible. - Identifies and resolves coding quality problems or issues in a timely manner. - Maintains continual knowledge of problems or issues that could affect coding quality levels. - Assists in design of systems to help improve coder productivity and assist in improving accuracy of coding. - Provides monthly reports. - Participates in corporate training and meetings. - Provides status reports to senior manager as requested. - Aligns conduct with AHIMA's Standards of Ethical Coding and the Company’s Code of Ethics and Business Conduct and supports the Company’s Ethics and Compliance Program. - Interprets coding guidelines for accurate code assignment. - Identifies the importance of documentation on code assignment and the subsequent reimbursement impact. - Complies with all internal policies and procedures. - Actively participates in Company provided training and education. - Ensures individual compliance with all privacy and security rules and regulations and commits to the protection of all Company confidential information, including but not limited to, Personal Health Information. Qualifications - Regular, predictable and punctual attendance is required. - Strong verbal and written communication skills are required. - Ability to prioritize workload, meet deadlines and maintain a high level of quality and accuracy. - Recognized coding credential from AHIMA or AAPC; RHIA or RHIT may also be considered. - Experience with telecommuting and electronic medical records systems strongly preferred. - Strong analytical skills. - Excellent written communication skills. - Strong team player. - Ability to work with multiple and diverse clients and projects. - Ability to work with minimal supervision. - Minimum 3 years of Profee coding experience and/or auditing in an acute care facility or multispecialty clinics. - Initiative, resourcefulness and attention to detail. - Customer service support -- minimum one (1) year experience. - Familiarity with hospital outpatient billing processes. - Understand hospital APC assignment and associated coding and documentation. - Coding Certification -- preferred (CPC or CCS). - Strong communication skills, proficient in Microsoft Office applications including Word and Excel. - Ability to navigate in a variety of EMR environments and review hand-written charts. Physical Demands Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.

Role Description Under general supervision, performs all functions associated with the appropriate assignment of ICD, HCPCS/CPT, and E&M codes for outpatient and/or inpatient encounters. - Assigns the appropriate ICD, HCPCS/CPT, and E&M codes, as applicable, to diagnoses and procedures generated for outpatient or inpatient encounters, maintaining a 95% accuracy rate in conjunction with meeting productivity standards. - Abstracts demographic and clinical data for performance improvement, research, reporting, and reimbursement purposes in relation to assigned areas of work by use of a computerized encoding system. - Validates charges on accounts/charge sessions. - Effectively interacts with providers and ancillary staff for clarification of coding issues. - Maintains statistics, records, and logs in relation to assigned work area. - Assists with the training and in-services of students and new employees in specific areas of assignment as directed by management. - Keeps educated about current coding updates per management’s direction – including ICD-10-CM, HCPCS/CPT, and E&M code guidelines and methodologies, as well as payor requirement changes as applicable. - Keeps management informed of coding problems/issues. - Represents coding on teams, committees, and task forces as assigned by management. - Actively participates in other duties as assigned, but only after appropriate training. Qualifications - Must have completed an American Health Information Management Association (AHIMA) approved program for Certified Coding Specialist, -OR- Health Information Technician (2 year degree), -OR- Health Information Administrator (4 year degree). - Certifications obtained: Certified Professional Coder (CPC) by an AAPC recognized program, -OR- Certified Coding Specialist-Professional (CCS-P), Registered Health Information Technician (RHIT), -OR- Registered Health Information Administrator (RHIA) by an AHIMA recognized program. - One year of coding experience is preferred -OR- an approved equivalent combination of education and experience. Requirements - Ability to communicate effectively both orally and in writing. - Ability to work independently with minimal direction.