[Hiring] Medical Records Technician Auditor @VA Manchester Healthcare System

Role Description

This position is located in the Health Information Management Section (HIMS) of the Business Office Service Line at the VAMC Manchester NH. MRTs (Coder) Auditors are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.

This remote option for this position will be assessed continuously, and if selected as a VA employee you may need to return to work to the nearest VA Office in the future, as determined by the agency policy.

Responsibilities

• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
• Reviews assigned codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
• Applies 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 for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Expertly 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.
• Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding.
• Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records.
• Audit function includes evaluation of clinical documentation to support optimal code assignment.
• 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 analyzes data.
• Facilitates improved overall quality, completeness and accuracy of coded data. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
• Responsible for performing 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.

Qualifications

• United States Citizenship
• 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 health records.
• 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.
• 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.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned.
• 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.

Benefits

• Work Schedule: Monday-Friday 8am-4:30pm.
• Compressed/Flexible: Not available.
• Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized.
• Permanent Change of Station (Relocation Assistance): Not Authorized.
• Remote/Virtual: This position is currently designated as remote.
• Permanent Change of Station (PCS): Not Authorized.
• PCS Appraised Value Offer (AVO): Not Authorized.

Company Description

Due to a critical staffing shortage, 38 U.S.C. § 7412 waives the requirement to apply Veterans' preference for this job announcement. This position is not a Bargaining Unit position.

Current and former Federal employees may submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (competitive or Excepted).

This position is covered by locality-based comparability pay. Applicants may be referred over for consideration prior to the close date of this announcement.

Narrative responses to the knowledge, skills and abilities (KSAs) may be required from the selectee in order to proceed with the appointment.