Medical Records Technician (Coder - Outpatient)

Department of Veterans Affairs • Tacoma, WA

52d • Onsite

About The Position

This position is in the Health Information Management (HIM) section at the VA Puget Sound HCS. The Medical Records Technician (Coder) is skilled in classifying medical data from patient health records in a hospital or clinical setting and assigns alpha-numeric codes specific to each diagnosis and procedure. To perform this, MRT's possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS). THIS IS NOT A REMOTE POSITION. WORK IS PERFORMED AT AT HE VA FACILTY IN TACOMA, WA. The duties listed are GS-8 Full Performance Level, GS-4, GS-5, GS-6, and GS-7 duties will differ in complexity and level of supervision. Outpatient Medical Coders analyze and abstract medical record data and assign codes using clinical classification systems. Medical coding requires independent judgment based on medical record documentation and personal coding knowledge and skill.

Requirements

• expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
• advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, principles and practices of health services, and the organizational structure to ensure proper code selection.

Responsibilities

• Perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and inpatient professional services.
• Perform a comprehensive review of documentation within the health record to accurately assign ICD-10- CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures, and evaluation and management services.
• Review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
• Code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties.
• Directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
• Abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
• Review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
• Enter and correct information that has been rejected, when necessary.
• Ensure audit findings have been corrected and refiled.
• Use various computer applications to abstract records, assign codes, and record and transmit data.
• Apply advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, principles and practices of health services, and the organizational structure to ensure proper code selection.
• Adhere 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.
• Apply codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
• Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided; provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Directly consult with the professional staff for clarification of conflicting or ambiguous clinical data.
• Expertly search the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
• Code diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
• Work within a team environment, support peers in meeting goals and deadlines, flexibility to handle multiple tasks, ability to work under pressure, and cope with frequently changing projects and deadlines.
• Respond to the needs of customers while supporting the VA mission.
• Communicate with and treat customers in a courteous, tactful, and respectful manner.

Benefits

• Competitive salary and regular salary increases.
• 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).
• 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.
• 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.
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA.
• Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement).
• Ad-hoc Telework

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Administration of Human Resource Programs
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees