US Veterans Health Administration

Duties Analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. Perform expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide education related to coding and documentation. Perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD-10-CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management 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...

Duties Coders perform inpatient coding duties. Abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided. Assigning codes to documented patient care encounters covering the full range of health care services provided by the CNVAMC. Performing a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture Assisting 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. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Utilizing the facility computer system and software applications to...

Duties Develops performance standards and conducts performance evaluations for subordinate staff. Interviews new employees, recommends selection, and carries out training and development of reassignments, awards or disciplinary action. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Keeps employees informed of management goals and objectives and higher levels supervisors informed of employee participation and concerns. Schedules 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. Revises schedules/assignments to meet changes in workload considering peak loads, availability of manpower and time limits. Makes changes in organization and assignment of duties to provide improvements, promote job satisfaction and increase productivity. Prepares workload and...