Medical Records Technician (CDIS-Outpatient and Inpatient)

This position is located in the Health Information Management (HIM) section at the Beckley VA Medical Center. 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.Total Rewards of a Allied Health ProfessionalDuties are but not limited too:Responsible for reviewing the overall quality and completeness of clinical documentation.The goal of these reviews is to ensure that all conditions monitored, evaluated, assessed and treated, or that impact the patient's care are documented as completely and precisely as possible and supported by the clinical indicators present in the health record.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 clinical documentation supports proper code selection and reporting of high-quality healthcare data.Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), CPT and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.Adheres to accepted coding practices, guidelines and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding.Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator.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.Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite.Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.Work Schedule: Monday - Friday, 8:00am - 4:30pmRecruitment Incentive (Sign-on Bonus): Not AuthorizedPermanent Change of Station (Relocation Assistance): Not AuthorizedPay: Competitive salary and regular salary increasesPaid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VAInsurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)Telework: Not AvailableVirtual: This is not a virtual position.Functional Statement #: 517-26372Permanent Change of Station (PCS): Not Authorized