Supervisory Medical Records Technician (Coder In/Out)

SummaryThis position is located in the Facility Support Directorate - within Patient Administration Department - Health Information Management (HIM) section at the Captain James A. Lovell Federal Health Care Center (FHCC). MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings.QualificationsApplicants 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 RequirementsThe following are the basic requirements and qualifications for this position: CERTIFICATION: Applicants at this level must have a mastery level certificationCurrent 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 recordsOR 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)Transcripts requiredOR 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 codingThe 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 completedOR EDUCATION/EXPERIENCE COMBINATION: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsThe 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 proceduresAlso - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)Transcripts requiredIN ADDITION TO MEETING THE BASIC REQUIREMENTS LISTED ABOVE - YOU MUST MEET THE SPECIALIZED EXPERIENCE AT THE GS-10 LEVEL TO QUALIFY FOR THIS POSITIONGRADE 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 positionSpecialized experience includes: responsible for the supervision - administrative management - and direction of coding staffThey are responsible for program management of a coding section/unit to ensure performance monitors are established and metThey 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 necessaryThey inform higher level management of anticipated vacancies or increases in workloadThey recommend employees for promotions - reassignments - recognitions - retention or release of probationary employees - or other changes of assigned personnelThey make decisions on the selection of employees for vacant or new positionsThey serve as an expert coding resource to ensure accuracy and integrity of all codingThey collaborate with revenue - compliance - and other departments to support coding accuracy that is consistent with the official guidelines for coding and reportingThey resolve claim edits referred to coding management and monitor reports for outstanding services - rejects - or uncoded episodes of care for inpatients and/or outpatientsThe supervisory coder ensures claim denials related to coding errors are resolved - and/or daily coding rejects are corrected for accurate billing and data collectionThey provide education to clinical and coding staffThey assess current audit findings and evaluate impact to coding and documentation practicesAND 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 fashionAdvanced 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 trainingLeadership and managerial skills - including skill in interpersonal relations and conflict resolution to deal with employees - team leaders - and managersAbility to collect and analyze data - identify trends - and present results in various formatsReference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/The full performance level of this vacancy is GS-10Physical Requirements: The work is primarily sedentaryPhysical demands do not exceed those of a typical office settingThere may be some walking - standing - twisting - turning - sitting - pushing - bending - repetitive keyboarding - or carrying of light items.DutiesApplicants must be able to perform all duties of a Supervisory MRT (Coder In/Out) which include: 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 selectionSelects 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 codingAlso 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 needsMonitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMCTimely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programsPerforms a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data captureThe 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 programsAssists 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 sequencingInsures provider documentation is complete and supports the diagnoses and procedures codedDirectly consults with the professional staff for clarification of conflicting or ambiguous clinical dataReports incorrect documentation or codes in the electronic patient health recordUses a variety of computer applications in day to day activities and duties - such as Outlook - Excel - Word - and Accesscompetent in use of the health record applications (VistA and CPRS) as well as the encoder product suiteEnsures current versions of all software applications are loaded and functional after any updates or changesWorks within a team environmentsupports staff in meeting goals and deadlinesflexible and handles multiple tasksworks under pressureand copes with frequently changing projects and deadlinesDevelops performance standards and conducts performance evaluations for subordinate staffInterviews new employees - recommends selection - and carries out training and development of reassignments - awards or disciplinary actionApproves leave schedulesImplements provisions of EEO programs to ensure fair and equal treatment for all employeesKeeps employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concernsSchedules 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 deadlinesRevises schedules/assignments to meet changes in workload considering peak loads - availability of manpower and time limitsMakes changes in organization and assignment of duties to provide improvements - promote job satisfaction and increase productivityPrepares workload and production reportsreports on operations and problems encounteredand presents proposed requests for resource needs based on past experience - anticipated staffing - equipment - and spaceCoordinates 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 ServicesKeeps abreast of all regulations and guidelines governing the coding section - ensuring that staff supervised is educated as neededEnsures that regulatory guidelines and current coding conventions are followedOther duties as assignedWork Schedule: Monday - Friday7:30 am - 4:00 pm (CST) Telework: Ad-hocVirtual: This is not a virtual positionFunctional Statement #: 07784F Relocation/Recruitment Incentives: Not AuthorizedPermanent Change of Station (PCS): Not Authorized.