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This position is for a Medical Record Technician (MRT) - Coder- in the Revenue Section of Fiscal Service at the Dayton VA Medical Center, Dayton, OH. The MRT reports to the coding supervisor & is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. The MRT will perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties.
- Assigns codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services;
- Applies advanced 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;
- Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS);
- Adheres 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;
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs;
- Performs a comprehensive review of the patient 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/ accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, reimbursement, workload, accepted nomenclature, and proper sequencing;
- Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record;
- Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data. Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines;
- Conducts re-reviews of codes abstracted for patient encounters identified by the VERA committee to determine if based on the documentation the specific VERA coding requirements were followed;
- Codes diagnoses from paper forms for VA registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.
Work Schedule: Monday - Friday 8:00 - 4:30pm
Financial Disclosure Report: Not required
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/521421400. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.