This position is located in the Health Information Management Section (HIMS) at the Charlie Norwood VA Medical Center Downtown or Uptown Division. The Medical Records Technician (Coder) is responsible for performing a quality review of Inpatient care documents and assigning codes specific for the type of care provided.Learn more about this agency
Some of the duties include, but are not limited to:
- Abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.
- Assigning codes to documented patient care encounters covering the full range of health care services provided by the CNVAMC.
- Performing a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture
- Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded.
- Utilizing the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin
- Conducting re-reviews of codes abstracted for patient encounters (inpatient) identified by the 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.
- Identifying the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).
Work Schedule: 8 a.m. - 4:30 pm
Telework Eligible: Yes
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/600253500. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.