Medical Records Technician (Coder) Auditor

Summary

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.

Duties

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 positions. 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.

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 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 Certific