Medical Records Technician (Coder) Auditor

US-Department-of-Veterans-Affair; Manchester (NH); Hybrid; USD 60,000 - 78,000; Full time

Job summary

U.S. Department of Veterans Affairs in Manchester, NH seeks a Medical Records Technician (Coder) Auditor to perform audits, ensure coding accuracy, and maintain compliance with ICD, CPT, and HCPCS standards.

The role requires knowledge of medical terminology and health records, with certifications through AHIMA or AAPC preferred. A remote option is assessed, with potential return to a VA office as policy requires.

Qualifications

• One year of creditable experience showing knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records structure.
• Completion of an AHIMA or AAPC coding program or equivalent training leading to coding certification eligibility.
• Educational substitutions allowed via combinations of experience and coursework in health information management.

Responsibilities

• Audit encounters to identify non-compliance in coding across outpatient and inpatient settings.
• Provide recommendations on coding to improve accuracy and documentation quality.
• Develop guidelines for data quality and monitoring to ensure fully documented and supported codes.

Skills

Medical terminology

Anatomy & physiology

Medical coding

Auditing

ICD CPT HCPCS

Education

Associate degree in health information tech

AHIMA/AAPC certification

AHIMA approved coding program

Job description

This position is located in the Health Information Management Section (HIMS) of the Business Office Service Line at the VAMC Manchester NH. MRTs (Coder) Auditors are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.

This remote option for this position will be assessed continuously, and if selected as a VA employee you may need to return to work to the nearest VA Office in the future, as determined by the agency policy.

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

Experience and Education.

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,

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,

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

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) Must have 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.

Grade Determinations

Medical Records Technician (Coder) Auditor, GS-09:

The MRT (Coder) Auditor assignment is a position above the journey level. Auditor assignments can be established for any of the coder subspecialties(outpatient, inpatient, or outpatient and inpatient combined). The subspecialty will be reflected in the title, e.g., MRT (Coder) Auditor.

Experience.

One year of creditable experience equivalent to the journey grade level (GS-08) of a MRT (Coder).

Certification.

Employees at this level must have a mastery level certification.

Demonstrated Knowledge, Skills, and Abilities

• Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).
• 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.

Assignment.

For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time.

• Auditors must be able to perform all duties of a MRT (Coder):
• 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 utilize results to identify documentation and 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 for clinical, financial, and administrative data to 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.

Preferred Experience: Previous experience in auditing in both Outpatient, inpatient and surgical settings. Previous experience in training coding and clinical staff on coding guidelines.

Reference:

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

VA Handbook 5005/122 PART II APPENDIX G57

The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is GS-09.

Physical Physical Requirements:

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