Medical Records Technician Coder - Auditor

Full Job Description

This position is located in the Health Information Management (HIM) Section of the Patient Administration Department at the Captain James A.

Lovell Federal Health Care Center (FHCC) in North Chicago, IL.

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

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.

Experience and Education 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, 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, 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, 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: Apprentice/Associate Level Certification through AHIMA or AAPC.

Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. English Language Proficiency.

MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

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).

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. NOTE: See paragraph 2g for a detailed definition of 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.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-09. Major Duties:

Total Rewards of a Allied Health Professional Auditors must be able to perform all duties of a MRT (Coder) Auditor: Serve as experts of current coding conventions and guidelines related to professional and facility coding.

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

Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.

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

Consult with the clinical staff for clarification of conflicting or ambiguous clinical data.

Use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes.

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.

Plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports.

Assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all coded data is fully documented and supported.

Maintain statistical databases to track the results and validate the program. Identify patterns and variations in coding practices with regular reports to the medical staff and management.

The Medical Record Tech (Coder-Auditor) position is authorized to telework during the Return to Office (RTO) Mid-term Extension through 04-30-26.

Per 10-31-25 Memo from the Acting Under Secretary for Health, "Approval for Mid-term Extension to Return to In-Person Work Requirement," this position is considered part of a series permitted to continue teleworking through 04-30-26." Approval to continue regular reoccurring telework or remote status is contingent upon approval/denial of the RTO Exemption.

Work Schedule: Monday - Friday, 7:30 am - 4:00 pm Recruitment Incentive (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): Not authorized Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Available Virtual: This is not a virtual position.

Functional Statement #: 07790F Permanent Change of Station (PCS): Not authorized PCS Appraised Value Offer (AVO): Not authorized