Medical Records Technician (Coder) Auditor

Full Job Description

This position is in the Health Information Management (HIM) section at the Durham VA Health Care System.

The Medical Record Technician (Coder) Auditor is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

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: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

*English Language Proficiency: MRTs (Coders) must be proficient in spoken and written English as required by 38 U.S. C. 7403. *Experience and Education: 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 12semester 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: 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.

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 the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC). 2.

Master 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 assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.

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).

Grade Determinations: Medical Records Technician (Coder) Auditor, GS-9 Experience. One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder). Certification.

Employees at this level must have a mastery level certification.

Detailed definition of mastery level certification: This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC.

To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation.

Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications.

Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies.

However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P),Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder(COC), Certified Inpatient Coder (CIC).

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 G57The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is GS-09.

Physical Requirements: The work is generally sedentary; however, there will be some walking, standing, bending, and carrying of light items such as papers and books.

The tasks may require long periods at a desk working on personal computer or other piece of equipment. Major Duties:

The duties of the Auditor will include, but are not limited to: Serves as expert of current coding conventions and regulations related to professional and facility coding.

Performs audits of encounters to identify areas of non-compliance in coding.

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

Works with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective actions.

Performs prospective coding audits and utilizes results to identify processing inadequacies and re-educate coding staff where necessary.

Coordinates retrospective reviews to ensure adequate auditing of coding activities. Acts independently to plan, organize, direct and control areas with emphasis on data validation.

Generates reports associated with the Medical Center's Health Information Management Program.

Determines quality control measures needed; initiates and implements them by use of monitors and/or continuous review. Work Schedule: Monday through Friday, 8:00 a.m. - 4:30 p.m.

Compressed/Flexible Schedule: Available Telework: Available *VIRTUAL tours of duty may be available for highly qualified candidates*Financial Disclosure Report: Not required