MEDICAL RECORDS TECH (CODER)- Auditor Inpatient/Outpatient

Veterans Health Administration; Fayetteville (AR); On-site; USD 60,000 - 85,000; Full time

Job summary

The Veterans Health Administration seeks a Medical Records Technologist (MRT) Auditor to classify medical data from inpatient and outpatient health records. The role requires knowledge of ICD-10-CM, CPT, and HCPCS, plus AHIMA/AAPC certification or equivalent education.

Auditors ensure accurate coding, support documentation quality, and work under VA guidelines in a hospital setting. Candidates should have an associate degree in health information management or an approved coding program.

Qualifications

• One year of creditable experience in medical terminology, anatomy, physiology, coding, and health records.
• Alternative education pathways with 12 semester hours in health information management are acceptable.
• Completion of AHIMA/AAPC coding program leading to eligibility for coding certification.
• Combination of education and experience is allowed for meeting the basics.

Responsibilities

• Audit encounters to assign codes using ICD-10-CM, CPT, and HCPCS with accuracy.
• Identify non-compliance and provide recommendations to improve data quality.
• Maintain current knowledge of coding guidelines and documentation requirements.
• Assist clinical staff with documentation for complete and accurate coding.

Skills

Medical terminology

Anatomy & physiology

Pathophysiology

Medical coding

ICD-10-CM

CPT/HCPCS coding

Education

Associate degree in Health Information Management

AHIMA/AAPC coding program completion

Courses in medical terminology, anatomy & physiology

Job description

This position is located in the Health Information Management (HIM) section at the Fayetteville VA NC Coastal Health Care System. MRT Auditors are skilled in classifying medical data from inpatient/outpatient health records in the hospital setting, and/or physician-based settings, such as physician offices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis & procedure.

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

Experience and Education

(1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.

OR,

(2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records);

OR,

(3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed

OR,

(4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.
(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).

Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:(1) Apprentice/Associate Level Certification through AHIMA or AAPC.(2) Mastery Level Certification through AHIMA or AAPC.(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

GS-09 Grade Determinations

In addition to the Basic Requirements above, candidates must also meet any additional requirements to include KSAs based on grade assignment, GS-9, below.

Experience. One year of creditable experience equivalent to the journey grade level, GS-8, of a MRT (Coder). Experience includes: performing all duties of a MRT (Coder) which includes: select and assign codes from current versions of ICD 10 CM, CPT, and HCPCS classification systems to outpatient records, including ambulatory surgeries.

Certification. Employees at this level must have a mastery level AHIMA or AAPC certificate. (You must provide this certification as a part of your application package. If you do not provide the proof of certification, your application will be screened out for not meeting this requirement).

Assignments: Auditors must be able to perform all duties of a MRT (Coder) (Outpatient and Inpatient). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data. They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. They assist facility staff with documentation requirements to completely and accurately reflect the patient care provided. They provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data. They use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. They perform prospective and retrospective coding audits and use results to identify documentation, coding inadequacies, and re-educate clinical and coding staff based on audit results. They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports. They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data. They ensure that all coded data is fully documented and supported. They maintain statistical database(s) to track the results and validate the program. They identify patterns and variations in coding practices with regular reports to the medical staff and management.

Demonstrated Knowledge, Skills, and Abilities (KSAs)

• Advanced knowledge of current outpatient coding classification systems such as ICD, CPT, and HCPCS
• Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
• Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.
• Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
• Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

Preferred Experience

• -must have CPC/RHIT/RHIA Certification
• -coding/auditing experience required/ upload
• Coding certification from AAPC/AHIMA
• -customer service experience

Reference

For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is GS-09.

Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service.