<p>This position is located in the Health Information Management (HIM) section at the. 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.</p> <p>Major duties and responsibilities include, but may not be limited to:</p> <ul> <li>Responsible for reviewing the overall quality and completeness of clinical documentation. Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. </li><li>Applies comprehensive 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 and reporting high-quality healthcare data. </li><li>Reviews clinical documentation and provides education to clinical staff on outpatient episodes of care. </li><li>Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. </li><li>Provides education to providers on the need for accurate and complete documentation in the health record, to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. </li><li>Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. </li><li>Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator. </li><li>Ensures documentation supports 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. </li><li>Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite. </li><li>Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. </li><li>Ensures active intra-departmental training program is in place for the HIM staff. Determines and meets training needs of extra-departmental professional, para-professional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital. </li><li>Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis. Identifies trends and/or opportunities to improve clinical documentation. </li><li>Collaboratively works with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. </li><li>Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management. </li><li>Performs other duties as required. </li></ul> <p>Total Rewards of a Allied Health Professional</p> <p>Work Schedule: Monday - Friday; 8:00 am - 4:30 pm</p> <p>Recruitment Incentive (Sign-on Bonus): Not Authorized</p> <p>Permanent Change of Station (Relocation Assistance): Not Authorized</p> <p>Paid Time Off: 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)</p> <p>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.</p> <p>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.</p> <p>Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA</p> <p>Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)</p> <p>Telework: Not Available</p> <p>Virtual: This is not a virtual position.</p> <p>Permanent Change of Station (PCS): Not Authorized</p>