Medical Record Technician (Coder) Auditor

Veterans Affairs, Veterans Health Administration - Lebanon, PA (30+ days ago)3.9

As a Medical Record Technician (Coder) Auditor in the Health Information Management Services section you will have the following responsibilities and duties:

Assigns and audits medical codes for documented patient care encounters covering the full range of health care services.
Applies advanced knowledge of clinical classification/coding systems,medical terminology, anatomy & physiology, disease process/ pathophysiology, treatment modalities, diagnostic tests, pharmacology, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Selects, assigns, and reviews codes from the current version of several clinical classification systems.
Adheres to accepted coding practices,guidelines and conventions when selecting the most appropriate diagnosis, operation, procedure, ancillary,or Evaluation and Management code(s) to ensure ethical,accurate, and complete medical coding.
Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
Monitors ever-changing regulatory and policy requirements affecting coded information.
Searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
Uses a variety of Window based applications in day to day activities and duties and competent in use of the health record applications.
Audits,assigns, and provides follow up regarding codes for the full spectrum of coding.
Reviews coding and assists coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data.
Performs audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
Performs other duties as assigned.

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. Must be proficient in spoken and written English
Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work. OR
Education: Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy and physiology, and introduction to health records). (TRANSCRIPTS REQUIRED) OR
Experience/Education Combination: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience: (a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record. (TRANSCRIPTS REQUIRED)

Preferred Experience:
Five years of direct hands-on outpatient medical coding experience;
Certified ICD-10 AHIMA Trainer;
Coding credentials such as Registered Health Information Technologist, Registered Health Information Administrator, Certified Coding Specialist, Certified Codidng Specialist - Professional, and Certified Professional Coder;
Course work in medical terminology, anatomy and physiology, and exposure to pharmacology;
Ability to code diagnoses, surgeries and procedures utilizing ICD-9-CM, CPT and HCPCS coding systems. Ability to apply modifiers as appropriate. Thorough understanding of ICD-9 Official Coding Guidelines. Understanding of medical necessity requirements;
Understanding of expanded Provider documentation requirements for upcoming ICD-10 implementation;
Participation in ICD-10-CM coding training and familiar with the major changes to medical coding based on the conversion to this new coding system;
Experience in Evaluation and Management Coding for professional services.

Grade Determinations:
Experience. One year of experience equivalent to the next lower grade level (GS-8) and must fully meet the KSAs at the GS-8 level:
1. Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments,
and the disease process/pathophysiology of the patient; and
2. Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient
professional fees; and
3. Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines.

In addition the candidate must demonstrate the following KSAs at the GS-9 level:
1. Knowledge of the applicable regulatory guidelines and requirements for current coding conventions; and
2. Knowledge of coding classification systems; and
3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions, and documentation requirements; and
4. Ability to format and present results and provide guidance to improve accuracy.

References: VA Handbook 5005/79, Part II, Appendix G35, Medical Record Technician Qualification Standards, 9/5/2014. This can be found in the local Human Resources Office.

The full performance level of this vacancy is GS-9.

Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals.

To apply for this position, you must provide a complete Application Package which includes:

VA Form 10-2850c

VA Form 10-2850c Application for Associated Health Occupations can be found at: (REQUIRED)
SF-50 "Official Personnel Action" - You must submit your most recent SF-50 that shows current position, title, occupation code, grade and step. Additional SF-50(s) will also be required to provide sufficient proof that time-in-grade requirements have been met for promotion. (REQUIRED)

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, documentation to support Veterans Preference or ICTAP/CTAP documentation (for displaced Federal employees).

Cover Letter
VA Form 10-2850c
VA Service Connected Letter

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit