Job Title
The job title is not provided in the raw HTML.
Job Description
Helps in assigning codes to documented patient care encounters (inpatient or outpatient) covering the full range of health care services provided by the VAACC. 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. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases-Clinical Modification (ICD-CM), Current Procedural Terminology (CPT), Diagnostic and Statistical Manual of Mental Disorders (DSM), and 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 (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. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Patient health records may be paper or electronic. 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. 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. Independently researches references to resolve any questionable code errors, contacts supervisor as appropriate. Uses a variety of window-based applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access. Ensures current versions of all software applications are loaded and functional after any updates or changes. 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. 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 and CPT 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 balance the workload among employees in accordance with established workflow or job specialization, 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. Required to train others on the encoder product suite. Utilizes this system on an ongoing basis to perform core coding duties and audits. 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. Serves as a backup coder for absences, staff shortages, and/or backlogs and performs other related duties as assigned or requested.
Work Schedule
Full time; Monday - Friday, 0800 - 1630
Telework
Regular Telework; 6+ Days per pay period.
Functional Statement #
929610
Relocation/Recruitment Incentives
Not Authorized
Permanent Change of Station (PCS)
Not Authorized