This position is located in the Health Management (HIM) section at the Orlando VA Healthcare System, MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, an/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

Duties

Apply comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic test, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Adhere 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. Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the OVAHCS. Perform comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete date capture. Prepare 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. Schedule 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. Make assignments that are equitable among employees. Formulate and issue written instructions and procedures and special instructions for non-routine or complex assignments or to clarify published guides. Keep abreast of all regulations and guidelines governing the coding section, ensuring that staff supervised is educated as needed. Coordinate 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. Monitor the status and progress of work and day-to-day adjustments in accordance wish established priorities. Give on the job training to new coders and students to provide the individual with the basic knowledge, skill and ability to perform the full range of routine and non-routine responsibilities require. Train and work closely with professional and administrative staff to assist in the development, maintenance and usage of ICD and CPT codes to ensure accurate data capture. Analyze and recommend improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources. Review compliance monitors with subordinates and identifies training needs. Utilize this system on an on-going basis to perform core coding duties and audits. Orients and instructs new personnel and/or students from affiliated health information or medical records technology programs on unit operations, coding, abstracting, and use of an electronic medical record. Interacts with health care providers, evaluating and communicating with the expectation on improving health record documentation which will result in improved patient care and improved revenue generation. Work Schedule: Monday- Friday 8:00am- 4:30pm Compressed/Flexible: Not available Telework: Available Virtual: This is a virtual position. Functional Statement #: 81748f Relocation/Recruitment Incentives: Not Authorized 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. 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. Experience and Education (1) 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, (2) 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, (3) 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, (4) 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: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) 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: Supervisory Medical Records Technician (Coder), GS-10 (a) Supervisory coder assignments can be established for any of the coder subspecialties (outpatient, inpatient, outpatient and inpatient combined). The subspecialty will be reflected in the title, e.g., Supervisory MRT (Coder- Outpatient). (b) Experience. One year of creditable experience equivalent to the next lower grade level. (c) Certification. Employees at this level must have a mastery level certification. NOTE: See paragraph 2g for a detailed definition of mastery level certification. (d) Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Supervisory MRTs (Coder) are responsible for supervising coding staff at the facility level. Supervisory MRTs (Coder) must be able to perform all duties of a MRT (Coder). The supervisory coder is 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. They oversee the reporting of coding and documentation audit results to leadership. They collect and prepare data for studies involving inpatient stays and outpatient encounters for clinical evaluation purposes, prepare and maintain a variety of complex records and daily, monthly, or "on demand" reports, as requested. The supervisory coder creates and monitors outpatient reports, inpatient case mix reports, top DRGs, and key performance indicators to identify patterns, trends, and variations. They investigate and evaluate potential causes for changes or problems and collaborate with the appropriate staff to effect resolution or explain variances. They participate in the formulation of objectives and strategies utilizing coded data to support goals for patient care, teaching, research, and optimizing management of resources. Supervisory MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Preferred Experience: Certified Coding Specialist (CCS), Certified Coding Specialist , Physician based (CCS-P), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC), Registered Health Information Technician (RHIT) and Registered Health Information Administrator (RHIA). Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is a GS-8. The actual grade at which an applicant may be selected for this vacancy is a GS-10. Physical Requirements: See VA Directive and Handbook 5019.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Orlando VA Medical Center 13800 Veterans Way Orlando, FL 32827 US
• Name: Nikki Merkes
• Phone: 727-398-6661 X64156
• Email: [email protected]