Supervisory Medical Records Technician

**Duties**:
Duties include the following:

- Comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery and procedures for accurate assignment of diagnosis related groups (DRG), and/or assigning CPT/HCPCS codes for Outpatient professional services.
- Independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
- Code all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of Outpatient specialties.
- Abstract, assign, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
- Review provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
- Ensure Outpatient coding staff queries clinical staff with documentation requirements to support the coding process. Enter and correct information that has been rejected.
- Ensure audit findings have been corrected and refiled.
- Establish the primary and secondary diagnosis and procedure codes for encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided. Understand the CPT coding system for Third Party Insurance cost recovery and interpret instructional notations; bundle encounters when appropriate; identify non
- billable encounters.
- Review and code assigned Community Care for Outpatient or outpatient encounters using the paper or electronic documentation obtained from non-VA facilities such as Community Hospitals, Emergency Rooms, military facilities, etc.
- Adhere 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 adhere 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.
- Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services.
- Review record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data.
- Assist facility staff with basic documentation requirements to reflect the patient care provided; provide support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, accepted nomenclature, and proper sequencing. Insure provider documentation supports the diagnoses and procedures coded.

**Supervisory Functions**:

- Develop performance standards and conducts performance evaluations for subordinate staff. Interview new employees, recommend selection, and carry out training and development of reassignments, awards or disciplinary action. Approve leave schedules. Implement provisions of EEO programs to ensure fair and equal treatment for all employees. Keep employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concerns.
- Schedule the sequence of work and operations on a weekly, monthly and quarterly basis to assure even workflow and distribution, expeditious handling of priorities and the meeting of deadlines. Revise schedules/assignments to meet changes in workload considering peak loads, availability of manpower and time limits. Make changes in organization and assignment of duties to provide improvements, promote job satisfaction and increase productivity.
- Prepare workload and production reports; report on operations and problems encountered; and present proposed requests for resource needs based on past experience, anticipated staffing, equipment, and space.
- Make assignments that are equitable among employees. Formulate and issue written instructions and procedures and special instructions for non
- routine or complex assignments.
- Review coding and assist coders in improving coding accuracy; provide coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiate various reports and analyze data; and coordinate, assign, and monitor the workflow.

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

**Telework**: Not Applicable

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

**Functional Statement #**: 000000

**Relocation/Recruitment Incentives**: Not Authorized

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

**Fi**nancial Disclosure Report**: Not Re