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Medical Records Technician

3 months ago

Shreveport, Louisiana, United States Veterans Health Administration Full time
Current permanent VA employees and Federal employees from other federal agencies should apply under CBST TM.

Duties include but not limited to:


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 current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).

Adheres to 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.

Also 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.

Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.

Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

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.

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.

Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.

Ensures active intra-departmental training program is in place for the HIM staff.

Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.

Collaboratively works with the professional clinical staff and provides support and education on documentation issues.

Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported.

As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.

Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.

The documentation specialist is a member of the healthcare team, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.

Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines, e.g.

upcoding, DRG creep, etc.

Selection of the principal diagnosis and principal procedure, along with other diagnoses and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set (UHDDS).

Work Schedule
: 8:00am - 4:30pm, Monday - Friday

Telework
:
Available

Virtual:
This is not a virtual position.

Functional Statement #
:
F

Relocation/Recruitment Incentives
:
Not Authorized

Permanent Change of Station (PCS):
Not Authorized

PCS Appraised Value Offer (AVO):
Not Authorized

Fi

nancial Disclosure Report:
Not required

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