Medical Records Technician (Coder) Auditor

US Department of Veterans Affairs; United States; Remote; USD 75,000 - 110,000; Full time

Job summary

US Department of Veterans Affairs is seeking a skilled Medical Coder to support accurate diagnosis and procedure coding across a wide range of patient records. The role requires expertise in ICD-10-CM/PCS, CPT, and HCPCS coding, with an emphasis on compliant documentation and coding practices.

The coder will review, analyze, and audit coded data, ensuring alignment with VER A program requirements and payer guidelines. This position offers remote work options and regular daytime hours.

Qualifications

• Knowledge of ICD-10-CM/PCS, CPT, and HCPCS coding systems and guidelines.
• Ability to audit and verify coded data for accuracy and compliance.
• Monitoring regulatory changes affecting coding practices and payer policies.
• Assist staff with documentation requirements and proper sequencing.

Responsibilities

• Reviews assigned codes using ICD-10-CM/PCS, CPT, HCPCS.
• Audits coded data for accuracy and compliance with coding rules.
• Monitors regulatory updates affecting coded information for VA programs.
• Assists staff with documentation requirements and coding guidelines.
• Consults with professional staff for clarification of clinical data.

Skills

Medical terminology

ICD-10-CM/PCS

CPT/HCPCS coding

Regulatory compliance

Documentation guidance

Auditing & analytics

Job description

Job Title

Some duties include but are 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 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 (E/M) code to ensure ethical, accurate, and complete coding.

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. 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 patientcare provided; 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.

Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care(purchased care) coding.

Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records.

Audit function includes evaluation of clinical documentation to support optimal code assignment.

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.

Responsible for performing 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.

Work Schedule: Monday-Friday 8am-4:30pm.

Compressed/Flexible: Not available

Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized

Permanent Change of Station (Relocation Assistance): Not Authorized

Remote/Virtual: This position is currently designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work, does not imply permanent remote work status, will be assessed continuously, and the selected individual may need to return to a VA office if required.

Functional Statement #: F04759

Permanent Change of Station (PCS): Not Authorized

PCS Appraised Value Offer (AVO): Not Authorized

Notifications:

Due to a critical staffing shortage, 38 U.S.C. 7412 waives the requirement to apply Veterans' preference for this job announcement.

This position is not a Bargaining Unit position.

Current and former Federal employees may submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held. Do not submit an award SF-50.

This position is covered by locality-based comparability pay.

Applicants may be referred over for consideration prior to the close date of this announcement.

Narrative responses to the knowledge, skills and abilities (KSAs) may be required from the selectee in order to proceed with the appointment.