Medical Records Technician (Coder) Auditor (Auditor-Outpatient and Inpatient)

U.S. Department of Veterans Affairs; Cleveland (OH); On-site; USD 50,000 - 70,000; Full time

Job summary

An established industry player is seeking a detail-oriented Medical Records Technician (Coder) Auditor to join their team. This role involves analyzing health records to ensure accurate coding, adhering to strict guidelines, and maintaining high standards of documentation. The ideal candidate will have a mastery level certification and experience in medical terminology, anatomy, and coding systems. Join a dedicated team committed to improving healthcare outcomes and making a significant impact in the field of health information management. If you're passionate about coding and healthcare, this opportunity is perfect for you.

Qualifications

• Must possess mastery level certification through AHIMA or AAPC.
• 1 year of experience in medical coding and health records.

Responsibilities

• Analyze health records for accurate coding and documentation.
• Perform outpatient and inpatient coding tasks.

Skills

Medical Coding

Medical Terminology

Anatomy and Physiology

Health Record Management

Interpersonal Skills

Education

Associate's Degree in Health Information Technology

Completion of AHIMA approved coding program

Job description

The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder) Auditor. The Medical Records Technician (Coder) Auditor will function within in the Health Information Management Service (HIMS) section of Patient Care Administrative Service (PCAS).





Duties

Duties of the Medical Records Technician (Coder) Auditor include but are not limited to:

Requirements

Qualifications
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,

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:

• 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
• 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).

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).

Grade Determinations:
In addition to the basic requirements listed above, the following criteria must be met when determining the grade of candidates.

Medical Records Technician (Coder) Auditor (Auditor-Outpatient and Inpatient), GS-9
One year of creditable experience equivalent to the journey grade level GS-8 of a MRT (Coder). Creditable experience includes: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.

AND

Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have possess one of the following certifications:

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.

Employees at this level must have a Mastery Level Certification through AHIMA or AAPC. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).

AND

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

Preferred Experience: Preferred experience of at least 2 years. Employees at this level must have a mastery level certification. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).

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-9.

Physical Requirements: The work is mostly sedentary. It typically requires sitting with sustained periods of concentration. There will be some walking, standing, bending, and carrying of relatively light objects. The position may also require stooping, reaching, lifting, pulling, and other moderate exertion or strain. Incumbent may occasionally have to walk some distance to a meeting.