Medical Records Technician (Auditor-Inpatient Coder)

Veterans Health Administration • Saint Louis, MO

18h • Remote

About The Position

This position is in the Health Information Management (HIM) section at the VA St. Louis Health Care System. The Medical Records Technician (Coder) classifies medical data from patient health records in hospital and physician-based settings. The coder analyzes and abstracts health records and assigns alphanumeric codes for diagnoses and procedures. This role focuses on auditing inpatient coding and documentation.

The position is remote-work eligible and currently exempt from return-to-office requirements. Remote exemptions are reviewed annually and do not guarantee permanent remote status. It is not a virtual position. The work schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. The full performance level is GS-9, and the position is in the Excepted Service.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Proficiency in spoken and written English.
• Meet one of the basic qualification pathways: one year of qualifying experience; an associate's degree in health information technology/management or a related degree with at least 12 semester hours in the field; completion of an eligible AHIMA-approved or other qualifying intensive coding training program; or an approved combination of experience and education/training.
• Hold a current mastery-level AHIMA or AAPC certification. Listed certifications include CCS, CCS-P, RHIT, RHIA, CPC, COC, and CIC.
• For GS-9, have one year of creditable experience equivalent to the GS-8 journey grade level as a Medical Records Technician (Coder).
• Demonstrate advanced knowledge of relevant ICD, CPT, and HCPCS classification systems; ability to research and resolve complex coding questions accurately and promptly; ability to review coded data and documentation for compliance; ability to present audit results, identify trends, and provide guidance; and interpersonal and conflict-resolution skills across organizational levels.
• Pass the required pre-employment physical evaluation and background/security investigation, complete onboarding and application documentation, and meet applicable Selective Service requirements.
• Participate in the seasonal influenza vaccination program as a VA Health Care Personnel employee.
• Serve a one- or two-year trial period, subject to written certification for continued employment.

Nice To Haves

• Three or more years of experience coding and/or leading a coding team.

Responsibilities

• 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.
• Review assigned codes using current versions of ICD, CPT, and/or HCPCS coding systems.
• Apply accepted coding practices, guidelines, and conventions to validate appropriate diagnosis, operation, procedure, ancillary, and evaluation and management codes.
• Apply coding guidelines for diagnoses, procedures, and criteria used to classify VA patients under the Veterans Equitable Resource Allocation (VERA) program.
• Monitor regulatory and policy requirements affecting coded information across the full spectrum of services provided by the medical center.
• Assist facility staff with documentation requirements and provide technical support on regulations, policy, coding requirements, resident supervision, reimbursement, workload, nomenclature, and code sequencing.
• Audit inpatient health records for the accuracy and completeness of ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values, including review of clinical documentation supporting code assignment.
• Analyze audit results and prepare summary feedback and recommendations for individual coders and/or clinicians.
• Provide coding consultation to coders and/or clinicians on coding and documentation questions.
• Maintain statistical databases to track and validate the coding audit program, identify patterns and variations in coding practices, and provide regular reports to medical staff and management.

Benefits

• Competitive salary and regular salary increases; a higher step rate may be considered based on qualifications or VA needs.
• 37–50 days of annual paid time off per year, consisting of 13–26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.
• Up to 12 weeks of paid parental leave after 12 months of employment, in connection with birth, adoption, or foster-care placement.
• Eligible full-time employees may qualify for a childcare subsidy after 60 days of employment, subject to income, child eligibility, and maximum subsidy limits.
• Traditional federal pension with five-year vesting and a federal 401(k) with up to 5% in VA contributions.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs may be carried into retirement.

What This Job Offers

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