Medical Records Technician (Coder Inpatient)

This position is located in the Health Information Management (HIM) section at the Minneapolis VA Health Care Systems (ICVAHCS). The Medical Records Technician (Inpatient-Coder) is responsible for the technical duties related to abstracting medical record data and assigning codes using current clinical classifications systems appropriate for the type of care provided.

Announcement will close once 50 applicants is reached- Temporarily eligible for Remote work within 50 miles of a VA Medical Center. May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review.Major duties include: 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. Abstract, assign, and sequence codes appropriately that support services rendered and conditions documented and for medical necessity.

Directly consulUquery the clinical staff for clarification of conflicting, incomplete, missing or ambiguous clinical data in the health record. Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications as well as the principles and practices of health services and the organizational structure to ensure proper code selection. 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.

Review and resolve coding edits. Enter and correct information that has been rejected, when necessary. Ensure audit findings have been reviewed, corrected as necessary, apply appropriate comments and refiled.

Ensures all documentation is present, accurate, complete and in an appropriate format. Ensures that documentation meets Joint Commission and VA requirements. Identifies problems in documentation and forwards to supervisor as necessary.

Reviews documentation regarding conditions that have been adjudicated as a service connection (SC) condition or for special treatment authorities related to exposures or experiences and forwards to Utilization Review as appropriate. Performs a comprehensive review of the patient health record to abstract medical, ancillary, demographic, social, and administrative data to ensure complete data capture. Work Schedule: 7:00 AM - 1530 PM, Monday- Friday Remote: The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.

The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs). Telework: Not applicable, this is a remote position. Virtual: This is not a virtual position. Functional Statement #: 000000Relocation/Recruitment Incentives: Not Authorized