Medical Records Technician

4 weeks ago

Fargo, North Dakota, United States Veterans Health Administration Full time

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers.

This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest.

As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran.

This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community.

This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.


Major duties include:


Assigns codes to documented patient care encounters (inpatient or outpatient) for one or more specialty and subspecialty health care services provided by the VAMC.

Has knowledge of medical terminology, anatomy & physiology, diseases, treatments, diagnostic tests, and medications to ensure proper code selection.
Selects and assigns codes from the current version of one or more coding systems depending on regular/recurring duties.

Coding systems 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 adheres to the coding guidelines specific to 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.

Reviews health record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data. Patient health records may be paper or electronic.

Assists facility staff with basic documentation requirements to reflect the patient care provided; provides support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing.

Utilizes the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin.

Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines.

Identifies the principal diagnosis and principal procedure for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG).

Updates ICD diagnosis and procedure codes for the quarterly inpatient and Contract Nursing Home census; updates certain billable long stay (30+ days) inpatient admissions to reflect all patient conditions and care up for monthly billing.

Work Schedule
: 8:00 AM - 4:30 PM, Monday- Friday

Telework
:
Ad hoc.

Virtual:
This is not a virtual position.

Functional Statement #

: 000000

Relocation/Recruitment Incentives
:
Not Authorized

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