Role Description
This position is located in the Health Information Management (HIM) in Health Administration Service (HAS) at the Marion, IL VA Medical Center. The Lead Medical Records Technician (Coder) Outpatient and Inpatient is skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based setting, such as physician offices, group practices, multi-specialty clinics, and specialty centers.
The Lead MRT (Coder) monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. The duties include but are not limited to:
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Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials, and supplies.
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Gives on-the-job training to new coders and students to provide the individual with basic knowledge, skill, and ability to perform a full range of routine and non-routine responsibilities.
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Trains and works closely with professional and administrative staff to assist in the development, maintenance, and use of ICD and CPT codes to ensure accurate data capture.
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Conforms to standards and participates in the technical evaluation and validation of health records for compliance with The Joint Commission requirements, Center for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines.
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Distributes and balances the workload among employees in accordance with established workflows or job specialization, assuring timely accomplishment of the assigned workload.
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Reviews compliance monitors with supervisors and identifies training needs.
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Reviews audits, trains, monitors, and completes special assignments within specified time frames.
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Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources.
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Identifies training needs of individuals based on productivity and accuracy reports, rejects filing from billing, and spot checks.
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Makes recommendations to supervisor concerning disciplinary actions due to insufficient performance and identifies continuing education needs.
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Required to train others on the encoder products suite. Utilizes this system on an ongoing basis to perform core coding duties and audits.
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Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided.
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Has constant interaction with health care providers, evaluating, and communicating with the expectation of improving health record documentation, which will result in improved patient care and improved revenue generation.
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Educates providers through feedback, email queries, or informal meetings.
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Participates in the orientation of House Staff from affiliated medical schools and other personnel needed.
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Other duties as assigned.
Qualifications
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United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
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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.
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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.
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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.
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Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
Requirements
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Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC.
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English Language Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
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Mastery level certification is required for all positions above the journey level.
Benefits
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Work Schedule: Monday - Friday 8:00am - 4:30pm CST
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Telework: Not Eligible
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Virtual: This position is remote work eligible and is currently exempted from return to office requirements.
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Relocation/Recruitment Incentives: Not Authorized
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Permanent Change of Station (PCS): Not Authorized
Physical Requirements
Physical aspects associated with work required of this assignment are typical for the occupation and would generally not require a pre-placement examination.
