Summary
The Lead Medical Records Technician (Coder-Inpatient) performs the full scope of coding including assigning ICD-10-CM and ICD-10-PCS codes, abstracting records, chart analysis, peer review, and the review of diagnostic studies and procedures. The incumbent ensures accurate and complete coding. In addition, the lead supports the team by assisting with coding questions, providing coder education, and serving as a resource for complex cases to maintain coding quality and compliance.
Duties
Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities Instructs employees in specific tasks and job techniques and makes available written instructions, reference materials and supplies Gives 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 required Trains and works closely with professional and administrative staff to assist in the development, maintenance and usage of ICD-10-CM and PCS codes to ensure accurate data capture Conforms to standards and participates in the 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 Distributes and balances the workload among employees in accordance with established workflow or job specialization and assures timely accomplishment of the assigned workload Analyzes and recommends improvements in documentation systems used to provide patient care to optimize VERA workload, third-party reimbursement, and to manage resources Reviews compliance monitors with Supervisor and identifies training needs Reviews, audits, trains, monitors, and completes special assignments within specified time frames Identifies training needs of individuals based on productivity and accuracy reports, rejects from billing, and spot checks Makes recommendations to Supervisor concerning disciplinary actions due to insufficient performance and identifies continuing education needs Trains others on the encoder product suite and utilizes this system on an ongoing basis to perform core coding duties and audits Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided Has constant interaction 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 Educates providers through feedback, email queries, or informal meetings Participates in the orientation of House Staff from affiliated medical schools and other personnel as needed Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS Assigns codes to documented patient care encounters covering the full range of health care services Applies advanced 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 Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria 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 Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture Ensures 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 Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines Independently researches references to resolve any questionable code errors and contacts the supervisor as appropriate Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic health record Performs other duties as assigned Work Schedule: 7:30am - 4pm Recruitment/Relocation Incentive: Not Authorized Remote: This is a remote position.
Requirements
You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.
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/.
How you will be evaluated
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.