Supervisory Medical Records Technician (Coder)

U.S. Department of Veterans Affairs; Gary (IN); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Paid time off

Parental leave

Child care subsidy

Federal retirement benefits

Health/vision/dental coverage

Job summary

The U.S. Department of Veterans Affairs is seeking a MRT (Coder) in the Health Information Management (HIM) section at the Nebraska Western Iowa VA Medical Center.

The role focuses on classifying medical data from patient records and assigning ICD, CPT, and HCPCS codes in inpatient and outpatient settings. The coder will ensure documentation and coding accuracy, follow regulatory guidelines, and provide supervision and training to staff while supporting VER A workload and reimbursement

Qualifications

• Proficiency in medical terminology and human anatomy/physiology.
• Experience applying ICD, CPT, and HCPCS coding systems.
• Ability to follow coding guidelines and regulatory requirements.

Responsibilities

• Selects and assigns codes from ICD, CPT, and HCPCS for inpatient and outpatient settings.
• Ensures coding accuracy and compliance with coding guidelines and regulations.
• Provides oversight of coding functions, staffing, workflow, and deadlines.
• Mentors staff, conducts training, and develops performance standards.
• Reviews provider documentation to ensure it supports diagnoses and procedures.
• Supports VER A program classification and resource allocation.

Skills

Medical terminology

ICD/CPT/HCPCS coding

VERA guidelines

Team supervision

Job description

Summary

This position is located in the Health Information Management (HIM) section at the Nebraska Western Iowa 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.

Duties

• Total Rewards of a Allied Health Professional Basic Functions: 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 selection
• Selects and assigns codes from the current version of several coding systems to include ICD - CPT - and/or 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 (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 needs
• 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
• Works within a team environment
• supports staff in meeting goals and deadlines
• flexible and handles multiple tasks
• works under pressure
• and copes with frequently changing projects and deadlines
• Supervisory Functions: Provides daily operational oversight of all coding functions to ensure needs are met by adjusting staffing - investigating workflow issues - answering coder questions - ensuring turnaround times are maintained - developing action plans - and following appropriate escalations
• Ensures coding practices meet regulatory guidelines and compliance goals of the organization
• Develops performance standards and conducts performance evaluations for subordinate staff
• Interviews new employees - recommends selection - and carries out training and development activities - awards - or disciplinary action
• Schedules 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
• Revises schedules/assignments to meet changes in workload considering peak loads - availability of manpower and time limits
• 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
• Reviews coding and assist coders in improving coding accuracy
• provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations
• initiates various reports and analyzes data
• and coordinates - assigns - and monitors the workflow
• 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 subordinates and identifies training needs
• Identifies training needs of individuals based on productivity and accuracy reports - rejects from billing - and spot checks
• Conducts provider training to improve health record documentation for the episodes of care provided
• Work Schedule: Monday-Friday 6:30am-3pm Recruitment/Relocation Incentives: Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases Paid 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) 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 VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Not applicable - this is a remote position
• Virtual: This is not a virtual position
• Permanent Change of Station (PCS): Not Authorized