This announcement is open to current, permanent Federal employees. All others should apply for consideration under CBDA-10568767-19-BOS-AMR.Learn more about this agency
This position is NOT VIRTUAL.
This position is located in the Health Information Management (HIM) section of the Business Operations Service at the Kansas City, VA Medical Center. The Lead Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. The lead coder reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyzes data; and may also coordinate, assign, and monitor the workflow.
Additional duties include, but are not limited to:
- Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-10-CM and ICD 10-PCS), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code.
- Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture.
- Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record.
- Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
- Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VISN VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
- Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program.
Functional Statement Title/#: Lead Medical Records Technician (Coder), GS-675-09
Job family (Series)
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/541753900. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.