Supervisory Medical Records Technician (Coder)

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. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. 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. 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. 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. Has constant interaction with health care providers with the goal of improving health record documentation, which will result in improved patient care and improved revenue generation. Work Schedule: Monday-Friday 6:30am-3pm Telework: Not applicable, this is a remote position. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized