Job purpose

The Military Health System (MHS), the medical departments of each military service and individual Military Treatment Facilities (MTFs) are committed to providing safe, high quality health care services to the beneficiaries served. The 45th Medical Group provides ambulatory medical service to active duty and their enrolled members. As such, creating and maintaining accurate health records vitally contributes to quality health care services.

Duties and responsibilities

1.1. Responsible for assignment of accurate E&M, ICD-9/ICD-10, CPT and HCPCS codes and modifiers from medical record documentation.

1.2. Identifies and abstracts information from medical records (paper or electronic) for special studies and audits, internal and external. 

1.3. Works with CHCS, AHLTA, and Coding Compliance Editor (CCE) government unique database; specifically, the Ambulatory Data Module to enter proper coding information. Works with CCE software to ensure records are accurately coded. 

1.4 Interacts with professional staff to ensure documentation is clear and supports coding assignments. Educates providers through individual or group in-services and training sessions.

1.5. Maintains a delinquency report of missing records in order to facilitate the completion of work within the required Air Force thresholds.

1.6. Works closely with the Coding Supervisor and the AFMOA Central Auditors during audit procedures. Ensure corrective actions and provide training based on audit results. Completes focused audits with the Coding Supervisor and shares results with the AFOMOA Coding.

1.7. Ensures all required component parts of the medical record that pertain to coding are present, accurate and comply with DoD, Air Force and AAAHC requirements.

1.8. Has significant role in departmental and clinic-wide coding compliance activities.

1.9. Identifies and corrects write back errors and coding validation notification report (C10) discrepancies. 

Qualifications

• Must be able to obtain a Pubic Trust Clearance.
• Excellent computer/communication skills for provider and staff interactions.
• Knowledge of anatomy/physiology and disease process, medical terminology, coding guidelines (outpatient), documentation requirements, familiarity with medications and reimbursement guidelines; and encoder experience.
• Ability to handle multiple projects and appropriately prioritize tasks to meet deadlines
• Certification in one of the following: Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder-Hospital (CPC-H), Certified Professional Coder (CPC), Certified Coder Specialist-Physician (CCS-P) with the appropriate level of education/experience. Education accreditation authority by either the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coder (AAPC)
• A minimum of five (5) years of coding (not billing) experience
• Ability to read, write, understand, and speak English fluently

Working conditions

Working conditions are within a normal office environment.

Physical requirements

Normal office environment mobility; sitting, walking, bending, stooping, standing, lifting a maximum of 25 pounds (greater than 25 pounds requires a two-person lift), turning, pushing. Normal office dexterity, to include; reaching, handling, grasping, to include typing/keyboard, and phone use.