Supvervisory Medical Records Technician (Coder)

US Department of Veterans Affairs; United States; Remote; USD 65,000 - 92,000; Full time

Job summary

The United States Department of Veterans Affairs is seeking a remote Medical Coder to apply ICD, CPT and HCPCS codes across inpatient and outpatient records. The position requires knowledge of VER A and regulatory coding guidelines, with careful attention to documentation supporting diagnoses and procedures.

Responsibilities include reviewing electronic health records for data abstraction, ensuring coding accuracy, supervising coding staff, and collaborating with clinical teams.

Qualifications

• Deep knowledge of medical terminology and anatomy.
• 2. Experience selecting ICD, CPT, and HCPCS codes.
• 3. Familiarity with VERA program and US healthcare coding rules.
• 4. Ability to review electronic health records for data abstraction.
• 5. Ensures documentation supports diagnoses and procedures.

Responsibilities

• Select and assign codes from ICD, CPT and HCPCS.
• Ensure coding accuracy and compliance with regulations.
• Review EHR data for completeness for billing and research.
• Provide guidance to staff on coding requirements.
• Coordinate with clinical staff to resolve coding ambiguities.

Skills

Medical terminology

Anatomy & physiology

ICD CPT HCPCS coding

VERA guidelines

Regulatory compliance

Electronic health record data

Documentation accuracy

Staff supervision

Job description

Job Title

Duties

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PLEASE NOTE: This position is designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S. Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements. Any selected candidate must live within 50 miles of a VA Medical Center .

• 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. The 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 programs.
• 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. Reports incorrect documentation or codes in the electronic patient health record.
• 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. Identifies, communicates, and ensures coding staff meet productivity and accuracy standards. Interviews new employees, recommends selection, and carries out training and development activities, awards, or disciplinary action. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Keeps employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concerns.
• Keeps abreast of all regulations and guidelines governing the coding section, ensuring all staff supervised are educated as needed. Ensures that regulatory guidelines and current coding conventions are followed.
• Coordinates with other unit/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 services. Promotes and ensures collaboration between coders, CDI, and charge services to facilitate complete and accurate coding. Assists with claims denial processes as it relates to coding issues.

Work Schedule : Monday - Friday 7:30am - 4:00pm Pacific Standard Time (PST)

Virtual: This is a virtual position

Functional Statement # : 00000

Relocation/Recruitment Incentives : Not Authorized

Permanent Change of Station (PCS): Not Authorized