MRT (Coder)Auditor

U.S. Department of Veterans Affairs; City of Syracuse (NY); On-site; USD 60,000 - 90,000; Full time

Job summary

The U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coder) Auditor at the Erie East VA Clinic.

The role requires expert knowledge of medical terminology, anatomy/physiology, coding systems, and health records management to ensure accurate code assignment and compliance across inpatient and outpatient records. Responsibilities include auditing ICD-10-CM/PCS, CPT, and HCPCS codes, researching guidelines, and guiding staff to improve documentation quality within a VA

Qualifications

• Knowledge of medical terminology, anatomy, physiology, and disease processes.
• Experience with medical coding systems (ICD-10-CM/PCS, CPT, HCPCS).
• Familiarity with health information management and health records structure.

Responsibilities

• Review and assign ICD-10-CM/PCS, CPT, and HCPCS codes accurately.
• Audit coded data for adherence to coding guidelines and completeness.
• Maintain knowledge of regulatory requirements affecting coded information.
• Provide coding guidance and support to staff to improve accuracy.

Skills

Medical terminology

Anatomy and physiology

Medical coding

Health records

Coding classifications (ICD/CPT/HCPCS)

Education

Associate's degree in health information technology/health information management

AHIMA/AAPC coding certification

AHIMA or ACDIS certification advancement

Tools

VistA

CPRS

Outlook

Excel

Access

Job description

Summary

The Medical Records Technician (Coder) Auditor position is located at the Erie East VA Clinic. MRTs (Coders) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics - and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

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
• 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 - 4
• 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) 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
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• 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: Medical Records Technician (Coder) Auditor - GS-9. The MRT (Coder) Auditor assignment is a position above the journey level
• Experience
• One year of creditable experience equivalent to the journey grade level of a MRT (Coder) - GS-8. Certification
• Employees at this level must have a Mastery Level Certification through AHIMA or AAPC
• Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: See VA Directive and Handbook 5019.

Duties

• Major duties and responsibilities of the position 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
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided
• provides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencing
• 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 - such as Outlook - Excel - Word - and Access
• competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite
• 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 accurate and complete assignment of ICD-10-CM - CPT - and HCPCS codes - including appropriate E/M assignment and modifier usage for outpatient health records
• 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
• As a technical expert in health information coding matters - 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
• Work Schedule: Monday to Friday - 7:00 am to 3:30 pm or 7:30 am to 4:00 pm
• Telework: ADHOC Virtual: This is not a virtual position
• Functional Statement #: 21N49-0 Relocation/Recruitment Incentives: Authorized for highly qualified applicants Permanent Change of Station (PCS): Not authorized.