Medical Records Technician (Coder) Auditor

Summary

The Medical Record Technician (Coder) Auditor position is located in the Health Information Management (HIM) section at the Thomas H. Corey VA Medical Center. Medical Record Technician (Coder) Auditors hold a mastery level certification, able to perform all duties of a MRT (Coder), and serve as experts of medical coding conventions and guidelines related to professional and facility coding.

Duties

• PLEASE NOTE: This Medical Records Technician (Coder) Auditor position is not remote and requires physical presence on-site.
• The Medical Records Technician (Coder) Auditor is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.
• Auditors serve as experts of current coding conventions and regulations related to professional and facility coding; perform audits of encounters to identify areas of non-compliance in coding; provide recommendation son appropriate coding; and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements.
• Auditors work with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective action; perform prospective coding audits and utilize results to identify processing inadequacies and re-educate coding
• Staff where necessary; and coordinate retrospective reviews to ensure adequate auditing of coding activities.
• Auditors act independently to plan, organize, direct and control areas wit emphasis on data validation, analysis and generation of reports associated with the Medical Center's health information management program.
• This incudes managing the professional health information management functions such as retrieving, reviewing and abstracting health record information.
• They also determine quality control measures needed; initiate and implement them by use of monitors and/or continuous review.
• Duties of the Medical
• Record Technician (Coder) Auditor include, but are not limit to: Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles of practices of health services and the organizational structure to ensure proper code selection.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• 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.
• Also 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Assists 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, ad proper sequencing.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
• Uses a variety of window based applications in day to day activities and duties, such as
• Outlook, Excel, Word, and
• Access; competent in use of the health record applications (VISA and CPRS) as well as the encoder product suite.
• Ensures current versions of all software applications are loaded and functional after any updates or changes.
• Work Schedule: 8am
• 4:30pm, Monday through Friday Telework: Not available. Functional Statement #: 40407F Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized

Requirements

• You must be a U.S.
• Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
• Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.
• As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
• In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the
• Government; and whether your continued employment would advance the efficiency of the
• Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Required Documents

• To apply for this position, you must provide a complete Application Package which includes:
• Resume Special Note for
• Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume
• This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.
• Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.
• The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former
• Federal employees), etc. Cover Letter
• DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) Professional Certification Resume Separation Notice (RIF)
• SF-15 SF-50/ Notification of Personnel Action Transcript