Medical Records Technician (Coder) Auditor (Inpatient)

Full Job Description

The Medical Records Technician (Coder) Auditor serves in the Health Information Management Section of Health Administration Service in the VA Long Beach Healthcare System (VALBHCS).

This position is located in the Health Information Management (HIM) section. REGARDING REMOTE WORK STATUS, PLEASE READ THE DUTIES SECTION OF THIS ANNOUNCEMENT.

Welcome to VA Long Beach Tibor Rubin - History 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.

English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience and Education (Basic Requirements) (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 (CDIS) assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers.

An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment.

At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.

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).

Grandfathering Provision.

All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation.

For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

(2) Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.

(3) MRTs who are appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.

(4) MRTs initially grandfathered into this occupation, who subsequently obtain additional education that meets all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

(5) Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

Grade Determinations: Medical Records Technician (Coder) Auditor, GS-9 Auditor assignments can be established for any of the coder subspecialties (outpatient, inpatient, or outpatient and inpatient combined).

The subspecialty will be reflected in the title, e.g., MRT (Coder) Auditor (Outpatient). Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder).

Certification. Employees at this level must have a mastery level certification. 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.

References: VA HANDBOOK 5005/122 PART II, APPENDIX G57 Physical Requirement: The work is primarily sedentary with prolonged periods of sitting.

The work requires moderate lifting, carrying, pushing, standing; reaching above shoulder; use of fingers; ability to read without strain; ability to hear the whispered voice with or without hearing aid; emotional & mental stability.

Major Duties:

PLEASE NOTE: This position is 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 will be assessed continuously, and the selected individual may need to return to a VA office if required.

The VA will categorically exempt military spouses authorized to engage in remote work and spouses of U.S.

Foreign Service members from Agency plans to return all eligible employees to in-person work instead of remote or telework arrangements.

Any selected candidate must live within 50 miles of a VA Medical Center.

Duties include, but are not limited to: Ability to work with a team to provide technical guidance, plan, organize, and coordinate activities in order to effectively complete job duties of assignment, such as distributing workload, monitoring the status and progress of work, monitoring accuracy of work, etc.

Advanced knowledge of current coding classification systems for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined) and the ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.

Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding.

They facilitate improved overall quality, completeness, and accuracy of coded data.

Provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements.

Provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.

perform prospective and retrospective coding audits and utilize results to identify documentation and coding inadequacies and re-educate clinical and coding staff based on audit results.

Ability to effectively communicate, both orally and in writing, in order to meet program objectives. Knowledge of training methods and the ability to provide training to new coding staff.

Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.

Leadership skills, including interpersonal relations and conflict resolution between employees, managers, and clinical staff. Work Schedule: Monday - Friday 7:30 a.m. - 4:30 p.m.

(Tour of duty is based on organizational needs) Telework: This position is telework eligible but may be required to return to the office permanently at a later date.

Virtual: This is a virtual position. Functional Statement #:PD000000 Financial Disclosure Report: Not required