Lead Medical Records Technician (Coder-Inpatient)

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-10-CM and PCS 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 balances the workload among employees in accordance with established workflow or job specialization and 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 Trains others on the encoder product suite and utilizes this system on an ongoing basis to perform core coding duties and audits Takes the initiative in one-on-one provider training to improve health record documentation for the episodes of care provided Has constant interaction with health care providers, evaluating and communicating with the expectation on improving health record documentation, which will result in improved patient care and improved revenue generation 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 Selects and assigns codes from the current version of several coding systems to include ICD, CPT, and/or HCPCS Assigns codes to documented patient care encounters covering the full range of health care services 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 and the organizational structure to ensure proper code selection 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 Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided Performs a comprehensive review of the electronic health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture 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 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 Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines Independently researches references to resolve any questionable code errors and contacts the supervisor as appropriate 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 Performs other duties as assigned Work Schedule: 7:30am - 4pm Recruitment/Relocation Incentive: Not Authorized Remote: This is a remote position.