Medical Records Technician (Coder) Auditor

Veterans Health Administration • San Diego, CA

8d • Remote

About The Position

The Medical Records Technician (Coder) Auditor is located in the Health Information Management section at the San Diego VA Medical Center. This above-journey-level role abstracts medical record data and assigns codes using current clinical classification systems appropriate to the care provided. The position audits coded data, evaluates documentation and coding quality, analyzes performance and trends, and provides guidance to staff to support accurate, complete, ethical, and compliant coding across inpatient and outpatient services.

The position is GS-09 and has a Monday–Friday schedule between 0700 and 1800. It is considered remote, but is not a virtual position; telework eligibility is noted as subject to possible return-to-office requirements. A mastery-level coding certification is required for this above-journey-level position, subject to the stated exception for clinical documentation improvement specialist assignments. The position is in the Excepted Service and requires a 1- or 2-year trial period.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Proficiency in written and spoken English.
• Meet time-in-grade requirements, including 52 weeks at the next lower grade, GS-08.
• Meet the basic experience and/or education requirements through one of the listed qualifying paths: one year of relevant experience; an associate’s degree in health information technology/management or a related degree with at least 12 relevant semester hours; completion of an eligible AHIMA-approved or other qualifying intensive coding program; or an appropriate combination of experience and education.
• Hold an eligible AHIMA or AAPC apprentice/associate-level or mastery-level certification, or a clinical documentation improvement certification through AHIMA or ACDIS; mastery-level certification is required for positions above the journey level, except that clinical documentation improvement certification may substitute for clinical documentation improvement specialist assignments.
• Have one year of creditable experience equivalent to the GS-08 journey-level Medical Records Technician (Coder).
• Hold a mastery-level certification for the GS-09 level, subject to the stated clinical documentation improvement specialist exception.
• Demonstrate advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the assigned subspecialty.
• Demonstrate the ability to research and accurately and promptly resolve complex questions about coding conventions and guidelines.
• Demonstrate the ability to review coded data and supporting documentation for compliance with standards, coding conventions, guidelines, and documentation requirements.
• Demonstrate the ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
• Demonstrate interpersonal and conflict-resolution skills for working with individuals at all organizational levels.
• Complete required background/security investigation and online onboarding; provide acceptable identification and complete application requirements.
• Participate in the seasonal influenza vaccination program as a condition of employment.
• Serve a 1- or 2-year trial period, subject to written certification for continued employment upon completion.

Responsibilities

• Abstract medical record data and assign codes using current clinical classification systems appropriate to the care provided.
• Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, health services, and organizational structure to select appropriate codes.
• Select and assign codes using current versions of ICD, CPT, and/or HCPCS.
• Follow accepted coding practices, guidelines, and conventions to select appropriate diagnoses, operations, procedures, ancillary, and Evaluation and Management codes.
• Apply coding guidelines for specified diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation program in inpatient and outpatient settings.
• Monitor changing regulatory and policy requirements affecting coded information for the full range of VAMC services.
• Assist facility staff with documentation requirements and provide technical support on regulations and policy, coding requirements, resident supervision, reimbursement, workload, nomenclature, and code sequencing.
• Search patient records for documentation that supports code assignments.
• Review, analyze, and report performance monitors for PTF, PCE, VERA, and Non-VA Medical Care coding.
• Review coding and assist coders in improving accuracy; provide coding guidance to staff to promote consistency and compliance.
• Initiate reports and analyze data.
• Audit coded data by developing criteria, collecting data, graphing and analyzing results, preparing reports, and communicating findings in writing or in person to leadership and other groups.

Benefits

• Federal employee benefits package for employees and their families; specific benefits and eligibility depend on position type and should be confirmed with the hiring agency.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree