Medical Record Tech

**Duties**:
**Major duties include but are not limited to**:

- Reviews the overall quality and completeness of outpatient encounters.
- Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
- Complies, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
- Performs chart reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the record.
- 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.
- Prepare and conduct provide education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
- Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
- Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator. Ensures documentation supports codes.
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Directly consults with staff for clarification on conflicting or ambiguous clinical data.
- Reports incorrect documentation or codes in the electronic patient health 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 HIM staff.
- Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary. May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation.
- Maintains statistical databases 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.

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

**Remote**: This is a remote position.

**Functional Statement #**: PD21P61A

**Relocation/Recruitment Incentives**: Not authorized

**Permanent Change of Station (PCS)**:Not authorized

**Fi**nancial Disclosure Report**: Not required

**Requirements**:
**Conditions of Employment**:

- Selective Service Registration is required for males born after 12/31/1959.
- Must be proficient in written and spoken English.
- You may be required to serve a probationary period.
- Subject to background/security investigation.
- Selected applicants will be required to complete an online onboarding process.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

**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.
- **English Language Proficiency.** MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. - 7403(f).
- **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 institutio