The Medical Record Technician (Coder) is located under the Health Information Management Division of the Facilities Support Directorate located at the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago, Illinois.Learn more about this agency
This position is responsible for maintaining the quality of patient records, assigning of appropriate International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.
- Assigns codes to documented patient care encounters (inpatient or outpatient) for the specialty and subspecialty health care services provided by the FHCC
- Assists 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
- Codes diagnosis, operations, and procedures based on knowledge of coding systems, including ICD, CPT and HCPCS, ensuring that codes are complete and conform to accepted VA regulations, Joint Commission, ICD coding conventions, and guidelines for optimal reimbursement
- Adheres to the coding guidelines specific to the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resources needs
- Identifies health record deficiencies, tracks deficiencies and ensures that appropriate individual completes their deficiencies
- Reviews and screens the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical record in a timely manner
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services
- Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program
- Codes all Operating Room procedures reported in the Surgical Package of the VistA hospital system; applies ICD and CPT coding systems and guidelines and selects proper codes
- Maintains confidentiality of all records and documents regarding patients
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/600549400. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.