Lead Medical Records Technician (Coder-Inpatient)

Summary The Inpatient Lead Coder must be able to perform all duties of an MRT (Coder). They serve as a subject matter expert and resource for coding staff and other health care professionals regarding coding guidelines, policies, and regulatory requirements for inpatient health records. Duties Temporarily eligible for Remote work within 50 miles of a VA Medical Center. May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review. Duties include but are not limited to the following: Performs and/or reviews the assignment of International Classification of Diseases, Clinical Modification (ICD-10-CM), ICD-10-PCS procedure codes, and Diagnosis Related Grouping (MS-DRGs or APR-DRGS) based on documentation within inpatient medical records. Conducts regular internal audits of inpatient coding to ensure accuracy, compliance with regulatory and VA policies, and appropriate reimbursement. Collaborates with providers, clinical documentation, resolve coding discrepancies, and support accurate clinical documentation. Provides direction and support to the inpatient coding team, assists in workload distribution, and acts as a coordinator for inpatient coding-related Initiatives. Orient and instruct new coding personnel and/or students on coding, abstracting and use of the electronic health recorder and encoder software. Ensure audit findings and claim denials related to coding errors are resolved and/or daily coding rejects corrected for accurate billing and data collection. Monitor trends and/or changes in regulatory and policy requirements affecting coding practices and identify educational needs. Develop coding training material and present a curriculum encompassing ongoing training initiatives. Provide assistance with coding inquiries from providers, MRTs (Coder), billers and other faculty staff. Other duties as assigned Work Schedule: Monday-Friday Administrative Hours Telework: Not applicable, this is a remote position. Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs). Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Qualifications Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Experience and Education Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Lead Medical Records Technician (Coder), GS-9 Experience. One year of creditable experience equivalent to the journey grade level MRT (Coder) (GS-8). Certification. Employees at this level must have a mastery level certification. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist

• Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc. Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. Ability to effectively communicate, both ora