Responsibilities

Apply comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and health services to ensure proper code selection.
Review assigned codes using current ICD, CPT, and HCPCS coding systems.
Apply guidelines specific to diagnoses, procedures, and other criteria used under the Veterans Equitable Resource Allocation (VERA) program.
Monitor regulatory and policy requirements affecting coded information for services provided by the VAMC.
Assist facility staff with documentation requirements to accurately reflect patient care.
Review, analyze, and report performance monitors for PTF, PCE, VERA, and Non-VA Medical Care coding.
Perform other duties as assigned.

Required Qualifications

Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records.
Ensure accuracy and completeness of coded clinical information used for reporting outcomes.
Perform audits of coded data, develop criteria, collect data, graph and analyze results, and create reports.
Communicate findings in writing and/or in person to leadership and other groups.
Collaborate with coding and clinical staff to provide support, education, and consultation on coding and documentation issues.
Research complex coding issues and participate in process improvements related to coding.
Minimum of 3 years' experience reviewing records.
Associate's degree or higher in Health Care.
One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure/format.
At least 2 years of Veterans Affairs or other relevant coding experience.
Experience using VIRR/WebVIRR.
Six additional months of creditable experience equivalent to an MRT (Coder).
Certification required: Apprentice/Associate level certification through AHIMA or AAPC.
Certification required: Mastery level certification through AHIMA or AAPC.
Certification required: Clinical Documentation Improvement certification through AHIMA or ACDIS.