Medical Records Technician (Coder) Auditor

U.S. Department of Veterans Affairs; San Diego (CA); On-site; USD 68,000 - 90,000; Full time

Job summary

The Medical Records Technician (Coder) Auditor at the San Diego VA Medical Center supports the Health Information Management (HIM) section by abstracting medical records and coding using ICD, CPT and HCPCS for care provided. Applicants pending completion of education or certification may be referred but may not be hired until all requirements are met.

This position requires time-in-grade at least 52 weeks at GS-08 and a mastery-level coding certification.

Qualifications

• One year of creditable experience showing knowledge of medical terminology, anatomy, physiology, pathology, medical coding, and health records structure.
• Education: Associate degree with 12+ semester hours in health information technology/management or related field, or AHIMA/AAPC coding program meeting certification eligibility.
• Certification: Mastery or equivalent certification through AHIMA/AAPC or clinical documentation improvement certification as required.
• Experience/education combinations may qualify when meeting basic requirements.

Responsibilities

• Abstract medical record data and assign codes using current ICD, CPT, and HCPCS classifications.
• Review coded data for adherence to standards and guidelines, ensuring accuracy.
• Present audit results and provide guidance to improve coding accuracy and compliance.

Skills

Medical coding knowledge

Audit & data review

Interpersonal skills

Education

Associate degree in health information technology/management

AHIMA/AAPC coding certification program

Job description

The Medical Records Technician (Coder) Auditor position is located in the Health Information Management (HIM) section at the San Diego VA Medical Center. 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. 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.

You must meet Time in Grade (TIG) as well as the qualifications below (52 weeks at the next lower grade-GS-08).

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.
• 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:
    1. Six months of creditable experience that indicates knowledge of medical 4 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.
    2. 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:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • 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.

You may qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation.

Grandfathering Provision

1. Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
2. Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
3. MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.
4. MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
5. Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

Grade Determinations

• Experience. One year of creditable experience equivalent to the journey grade level of a GS-08 MRT (Coder).
• Certification. Employees at this level must have a mastery level certification.

Knowledge, Skills, and Abilities (KSAs)

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

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.