Medical Records Technician (Coder/Audit/Training)

Summary

About the Position: The positions fall under the Defense Health Agency (DHA) Atlantic Network at the Naval Medical Center Portsmouth, Patient Administration Department (PAD) providing guidance and functional expertise to improve coding accuracy, and functioning primarily as a medical auditor/trainer. (See duties below). This is a Direct Hire Solicitation

Duties

• Analyze patient medical records to identify inaccurately coded services in accordance with federal coding regulations and guidelines.
• Assign specific codes to medical records, sequencing and determining codes to accurately reflect the resources and procedures used in the care of the patients.
• Ensure compliance with regulatory and third-party insurance requirements in utilizing the ICD-10-CM, and CPT coding books.
• Perform limited utilization review of outpatient and inpatient records to assure the diagnosis responsible for the length of stay is appropriately identified.
• Assure secondary diagnoses are sequenced properly to assure maximum allocation under the Relative Value Unit (RVU) and Diagnosis-Related Group (DRG) systems.
• Provide review and analysis of coding accuracy and compliance statistics, coordinating results with the Coding Manager and Patient Administration Department Head for feed back to the providers.
• Prepare reports of findings and recommends staff education and training on accurate coding practices and compliance issues to maintain coding accuracy.
• Provide monthly performance and progress reports addressing levels of accomplishment to Coding Manager and Patient Administration Department Head.
• Maintain thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs.
• Maintain a thorough understanding of medical record practices, standards, regulations, and Joint Commission requirements.
• Perform diagnosis and procedure coding through application of International Classification of Diseases, Clinical Modification (ICD-11-CM) current edition and Current Procedural Terminology (CPT) coding guidelines.
• Develop programs and plans for training medical and ancillary services staff in basic coding techniques and requirements.
• Work in coordination with the government electronic health record sustainment trainer as appropriate and recommends coding resources to enhance data quality.

Education

Some federal jobs allow you to substitute your education for the required experience in order to qualify. For this job, you must meet the qualification requirement using experience alone--no substitution of education for experience is permitted.