The VA Northeast Ohio Healthcare System is recruiting for a Lead Medical Records Technician (Coder). The Lead Medical Records Technician (Coder) will function in Health Information Management section in the Business Office Service.

Duties

Assigning codes to document patient care encounters (outpatient) using clinical classification systems including International Classification of Diseases (ICD), procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Applying advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code selection. Auditing for Inpatient DRG, ICD-10 PCS, CPT Surgery Outpatient and Evaluation & Management. Applying codes based on guidelines specific to certain diagnoses, procedures, and other criteria (inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program. Monitoring ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided. Providing technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insuring provider documentation is complete and supports the diagnoses and procedures coded. Consulting with the professional staff for clarification of conflicting or ambiguous clinical data. Searching the patient health record to find documentation justifying code assignment. Utilizing the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national database. Correcting identified data errors or inconsistencies to ensure acceptance in the national database. Monitoring the status and progress of work and day-to-day adjustments. Instructing employees in specific tasks and job techniques. Facilitating on the job training to coders and students. Distributing and balancing the workload among employees. Analyzing and recommending improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources. Reviewing compliance monitors and identifying training needs. Reviewing, auditing, training, monitoring, and completing special assignments. Identifying training needs of individuals based on productivity and accuracy reports. Participating in technical evaluation and validation of health records for compliance with the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines. Work Schedule: Monday - Friday, 8:00am - 4:30pm Telework: Eligible per agency policy Remote: Available for highly qualified candidates. Functional Statement #: 917990 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ? 7403(f) Experience and Education: Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR, Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records) OR, Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed OR, Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Grade Determinations: Lead Medical Records Technician (Coder-Outpatient), GS-9 Experience: One year of creditable experience equivalent to the journey grade level MRT (Coder). Specialized experience is defined as experience which equipped you with the particular knowledge, skills, and abilities to perform successfully the duties of the Lead Medical Record Technician (Coder), and that is typically in or related to the work of the position. Examples of specialized experience include, but are not limited to: Reviewing inpatient documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures; reviewing outpatient documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services; consulting with professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record; abstracting and sequencing codes into encoder software to obtain correct diagnosis related group (DRG); entering and correcting information that has been rejected; and correcting any identified data errors or inconsistencies. Certification. Employees at this level must have a mastery level certification. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc. ii. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. iii. Ability to effectively communicate, both orally and in writing, in order to meet program objectives. iv. Knowledge of training methods and the ability to provide training to new coding staff. v. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. vi. Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. References: VA Handbook 5005/122, Part II, Appendix G57 The full performance level of this vacancy is GS-9. Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Physical Requirements: The work is mostly sedentary. It typically requires sitting with sustained periods of concentration. There will be some walking, standing, bending, and carrying of relatively light objects. The position may also require stooping, reaching, lifting, pulling, and other moderate exertion or strain. Incumbent may occasionally have to walk some distance to a meeting.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address VA Northeast Ohio Healthcare System 10701 East Boulevard Cleveland, OH 44106 US
• Name: Teela Grant
• Phone: 216-791-2300 X42156
• Email: [email protected]