About the Position: This position is located within the Dept of Patient Administration, Inpatient Records at the Walter Reed National Military Medical Center in Bethesda, MD. Incumbent is responsible for translating, analyzing, and coding inpatient medical records which effects the accuracy and reliability of patient medical records. The work area is adequately lighted, heated, and ventilated. The work environment involves everyday risks or discomforts that require normal safety precautions.Learn more about this agency
- Utilize coding systems to code, review, and update medical diagnosis and procedures within patient medical records.
- Assign codes to all final diagnoses, procedures, and operations.
- Sequence codes utilizing the complication or comorbid condition exclusion list in the code book.
- Perform qualitative analysis of the records to ensure accuracy, internal consistency and correlation of recorded data.
- Assign additional diagnosis codes based on specific clinical findings (laboratory reports, radiology reports, pathology reports and clinical studies) in support of existing diagnoses (i.e., discharge summary/notes).
- Conduct group education briefings on coding; assists in the development and deployment of entry level training programs and provides training to assigned professional staff.
- Identify the diagnosis determined to be chiefly responsible for the admission of the patient to the hospital and code it as the principal diagnosis.
- Contact appropriate medical staff members to rectify inconsistencies, deficiencies and discrepancies in medical documentation without prompting from the supervisor.
- Making recommendations to improve procedures for compiling and retrieving medical records information.
- Determine diagnostic and procedural terminology used is consistent with current medical nomenclature.
- Review content of diagnostic and procedural templates in the Ambulatory Data System to ensure diagnoses and procedures meet current coding requirements.
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/533915600. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.