This position is located in the Health Information Management (HIM) section at the Edward Hines Jr. VA Hospital. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha numeric codes for each diagnosis and procedure.

Duties

Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. The abstracted data has many purposes, for example, to profile the facility services and patient population, to determine budgetary requirements, to report to accrediting and peer review organizations, to bill insurance companies and other agencies, and to support research programs. 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. Insures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes. Works within a team environment; supports staff in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines. Develops performance standards and conducts performance evaluations for subordinate staff. Interviews new employees, recommends selection, and carries out training and development of reassignments, awards or disciplinary action. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Keeps employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concerns. Schedules the sequence of work and operations on a weekly, monthly and quarterly basis to assure even workflow and distribution, expeditious handling of priorities and the meeting of deadlines. Revises schedules/assignments to meet changes in workload considering peak loads, availability of manpower and time limits. Makes changes in organization and assignment of duties to provide improvements, promote job satisfaction and increase productivity. Prepares workload and production reports; reports on operations and problems encountered; and presents proposed requests for resource needs based on past experience, anticipated staffing, equipment, and space. Coordinates with other Service representatives on matters concerning health record documentation and coding, as well as changes and challenges that may have an impact on other Units or Services. Keeps abreast of all regulations and guidelines governing the coding section, ensuring that staff supervised is educated as needed. Ensures that regulatory guidelines and current coding conventions are followed. Other duties as assigned. Work Schedule: Monday-Friday 7:30am-4:00pm Telework: As determined by agency policy-ADHOC Permanent Change of Station (PCS): Not Authorized

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. To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement. BASIC REQUIREMENTS: The following are the basic requirements and qualifications for this position: CERTIFICATION: Applicants 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). 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 EDUCATION/EXPERIENCE 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). IN ADDITION TO MEETING THE BASIC REQUIREMENTS LISTED ABOVE, YOU MUST MEET THE SPECIALIZED EXPERIENCE AT THE GS-10 LEVEL TO QUALIFY FOR THIS POSITION. GRADE REQUIREMENTS GS-10 SPECIALIZED EXPERIENCE: Must have at least one full year of specialized experience equivalent to at least the next lower grade level (GS-9) that equipped you with the particular knowledge, skills and abilities to perform successfully the duties of the position. Specialized experience includes: responsible for the supervision, administrative management, and direction of coding staff. They are responsible for program management of a coding section/unit to ensure performance monitors are established and met. They perform a full range of supervisory responsibilities, to include evaluating the performance of subordinate staff, approving sick and annual leave requests, identifying educational or training needs, resolving employee complaints, and taking disciplinary actions, when necessary. They inform higher level management of anticipated vacancies or increases in workload. They recommend employees for promotions, reassignments, recognitions, retention or release of probationary employees, or other changes of assigned personnel. They make decisions on the selection of employees for vacant or new positions. They serve as an expert coding resource to ensure accuracy and integrity of all coding. They collaborate with revenue, compliance, and other departments to support coding accuracy that is consistent with the official guidelines for coding and reporting. They resolve claim edits referred to coding management and monitor reports for outstanding services, rejects, or uncoded episodes of care for inpatients and/or outpatients. The supervisory coder ensures claim denials related to coding errors are resolved, and/or daily coding rejects are corrected for accurate billing and data collection. They provide education to clinical and coding staff. They assess current audit findings and evaluate impact to coding and documentation practices. AND You must demonstrate the following Knowledge, Skills and Abilities: Ability to perform a full range of supervisory duties, to include recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure duties are completed in an accurate and timely fashion. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). Ability to provide or coordinate staff development and training. Leadership and managerial skills, including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers. Ability to collect and analyze data, identify trends, and present results in various formats. References: See VA Handbook 5005, Part II, Appendix G57. The full performance level of this vacancy is GS-10. Physical Requirements: The work is primarily sedentary. Physical demands do not exceed those of a typical office setting. There may be some walking, standing, twisting, turning, sitting, pushing, bending, repetitive keyboarding, or carrying of light items.

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 Edward Hines Junior Hospital 5000 South 5th Avenue Hines, IL 60141 US
• Name: Frankie Fessler-Boylan
• Phone: 515-868-4959
• Email: [email protected]