Medical Records Technician (Coder)- Auditor

US Department of Veterans Affairs; Albuquerque (NM); On-site; USD 65,000 - 90,000; Full time

Job summary

US Department of Veterans Affairs in Albuquerque is seeking a Medical Coder to apply comprehensive knowledge of medical terminology, anatomy and coding systems to assign ICD-10-CM, CPT, and HCPCS codes for outpatient records. You will ensure compliance with VER A guidelines and regulatory requirements.

The role involves audits, data analysis, guidance to staff, and collaboration with clinical teams to improve documentation and reimbursement accuracy in a large healthcare system.

Qualifications

• Must demonstrate comprehensive knowledge of medical terminology, anatomy, physiology and coding rules.
• Experience with ICD-10-CM, CPT and HCPCS coding and related guidelines.
• Ability to audit and improve coding accuracy and determine data quality.
• Capable of providing coding guidance and staff training.
• Familiarity with VER A program guidelines and reimbursements.

Responsibilities

• Audit ICD-10-CM, CPT and HCPCS codes including E/M assignments for outpatient records.
• Review clinical documentation to ensure accurate code selection.
• Provide coding guidance to staff to promote consistency and compliance.
• Collaborate with clinical staff to improve documentation and coding.
• Research complex coding issues and participate in process improvements.
• Prepare reports and communicate audit results to leadership.

Skills

Medical coding

Documentation review

Regulatory knowledge

Data analysis

Audits

Training staff

Tools

ICD-10-CM systems

CPT coding

HCPCS coding

EMR systems

Job description

Job Title

Major duties and responsibilities include but not limited to:

• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Reviews assigned codes from the current version of several coding systems to include current versions of the ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code.
• Applies guidelines specific to certain diagnoses, procedures, and other criteria 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.
• Assists facility staff with documentation requirements.
• Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and 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 computer applications in day-to-day activities and duties.
• Ensures current versions of all software applications are loaded and functional after any updates or changes.
• Reviews, analyzes and reports performance monitors for PCE, VERA and Non-VA Medical Care (purchased care) coding.
• Audit accurate and complete assignment of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records.
• Evaluation of clinical documentation.
• Reviews coding and assist coders in improving coding accuracy.
• Provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations.
• Initiates various reports and analyze data.
• Facilitates improved overall quality, completeness and accuracy of coded data.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
• Perform audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
• Collaboratively works with coding staff and clinical staff to provide support and education on coding issues.
• Provides training and education to coding and clinical staff.
• Research complex coding issues and participates in process improvements related to coding.
• Assists in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data.
• Provides advice and guidance on documentation and coding requirements.
• Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines and audit standards, and results in appropriate data capture and reimbursement.
• Analyze audit results and prepare summary feedback for individual coders and/or clinicians, making recommendations for improvement.
• Provide coding consultation to coders and/or clinicians related to coding and documentation questions.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

Work Schedule: Monday thru Friday, 8:00am to 4:30pm or 7:30am to 4:00pm

Telework: Ad-Hoc at the discretion of the manager.

Virtual: This is not a virtual position.

Functional Statement #: 00000

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized