Medical Records Technician (Coder) - Department of Veterans Affairs - Augusta, ME

Medical Records Technician (Coder) perform quality review of patient care documents and assigning codes specific to the type of care provided. The duties include but are not limited to:

· Assigns codes to documented patient care encounters (inpatient and outpatient) 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 and keeps abreast of accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding.

· Performs a comprehensive review of the patient 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 record.

· Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national database.

· Corrects any identified data errors or inconsistencies in a timely manner.

· 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 medical record.

· Strictly complies with regulatory fraud and abuse guidelines and federal agency specific guidance for optimum allowable reimbursement.

· Codes diagnoses from paper forms for registries such as Agent Orange, Ionizing Radiation, Persian Gulf, Prisoner of War, etc.

· Incumbent works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.

· Protects and maintains the privacy and confidentiality of printed and electronic files in accordance with the applicable laws and regulations on confidentiality such as the Privacy Act, the Health Insurance Portability and Accountability Act, and the Freedom of Information Act.

Work Schedule: Monday – Friday 8:00am to 4:30pm.

Functional Statement: MRT (Coder) BSL

BASIC REQUIREMENTS:

Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit

qualified candidates in accordance with chapter 3, section A, paragraph 3g, this part.)

Experience. Two years of experience that demonstrates the applicant’s ability to perform the work, or provides familiarity with the work. Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT work. OR,