Medical Records Technician (Coder)- Auditor

Veterans Health Administration•Albuquerque, NM

2d•Onsite

About The Position

This position is in the Health Information Management (HIM) section at the Raymond G. Murphy VA Medical Center. The Medical Records Technician (Coder) Auditor classifies medical data from patient health records in hospital and physician-based settings. The role analyzes and abstracts patient records and assigns alphanumeric codes for diagnoses and procedures. The position audits outpatient coded data for accurate and complete assignment of ICD-10-CM, CPT, and HCPCS codes, including evaluation and management codes and modifiers. It evaluates clinical documentation, reviews coding, and helps coders improve accuracy. The auditor provides coding guidance, education, and consultation to coding and clinical staff; researches complex coding issues; and contributes to coding-related process improvements. The role also develops and performs audits, analyzes results and trends, prepares reports and feedback, and recommends improvements. It supports the quality, completeness, and accuracy of clinical, financial, and administrative data, maintains statistical databases, and monitors coding performance for PCE, VERA, and Non-VA Medical Care. The position keeps current with regulatory and policy requirements and assists staff with documentation and coding requirements. Work schedule is Monday through Friday, either 8:00 a.m. to 4:30 p.m. or 7:30 a.m. to 4:00 p.m. Ad hoc telework is at the manager’s discretion; this is not a virtual position.

Requirements

One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format; or a qualifying education, training, or experience-and-education combination described in the announcement.
For the GS-9 Auditor grade, one year of creditable experience equivalent to the GS-8 journey level as a Medical Records Technician (Coder).
Mastery Level Certification through AHIMA or AAPC for the GS-9 level.
Proficiency in spoken and written English.
Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the assigned subspecialty.
Ability to research and solve complex coding-convention and guideline questions accurately and promptly.
Ability to review coded data and supporting documentation for compliance with standards, coding conventions, guidelines, and documentation requirements.
Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.
Interpersonal and conflict-resolution skills to work with individuals at all organizational levels.
U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
For the GS-9 grade, the required certification is a Mastery Level Certification through AHIMA or AAPC.

Responsibilities

Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatments, diagnostic tests, medications, procedures, and health services organization to select appropriate codes.
Review and audit code assignments using current ICD, CPT, and HCPCS coding systems and applicable guidelines, conventions, and requirements.
Audit outpatient records for accurate and complete ICD-10-CM, CPT, and HCPCS coding, including appropriate evaluation and management code and modifier assignment.
Evaluate clinical documentation and search patient records to locate documentation supporting code assignments.
Apply coding criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program.
Monitor regulatory and policy requirements affecting coded information and support compliance with audit standards.
Assist facility staff with documentation requirements and provide technical support on regulations, coding, reimbursement, workload, nomenclature, sequencing, and resident supervision.
Consult with professional staff to clarify conflicting or ambiguous clinical data.
Review coding and assist coders in improving coding accuracy and consistency.
Provide coding guidance, education, training, and consultation to coding and clinical staff on coding and documentation questions.
Research complex coding issues and participate in coding-related process improvements.
Develop and perform audits, including setting criteria, collecting data, graphing and analyzing results, preparing reports, and communicating findings to leadership and relevant groups.
Analyze audit results, identify trends and variations, and provide feedback and recommendations for improvement to coders and clinicians.
Maintain statistical databases and report on coding patterns, performance, and program results.
Review, analyze, and report performance monitors for PCE, VERA, and Non-VA Medical Care coding.
Assist in developing data-quality, consistency, monitoring, and compliance guidelines.
Maintain current knowledge of coding and documentation requirements to support accurate data capture and reimbursement.
Use computer applications in daily work and ensure software applications remain current and functional after updates or changes.