[Hiring] Medical Records Technician (Coder) Auditor @Columbia VA Health Care System

Role Description

This position is located in the Health Information Management (HIM) section at the Columbia VA Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

This position is designated as remote. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.

Duties include but are not limited to:

• 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.
• Selects and assigns 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 code to ensure ethical, accurate, and complete coding.
• Applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• 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.
• Uses a variety of window-based applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
• Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding.
• Provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.
• 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.

Requirements

• Work Schedule: Monday - Friday, 8:00am - 4:30pm
• 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 off per year.
• Parental Leave: Up to 12 weeks of paid parental leave after 12 months of employment.
• Child Care Subsidy: Eligible for a childcare subsidy after 60 days of employment.
• Retirement: Traditional federal pension and federal 401K with up to 5% contributions by VA.
• Insurance: Federal health/vision/dental/term life/long-term care insurance.
• Telework: Not Available
• Virtual: This is not a virtual position.
• Functional Statement #: 57037F
• Permanent Change of Station (PCS): Not Authorized

Qualifications

• 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.
• English Language Proficiency: Proficient in basic written and spoken English.
• Experience and Education:
• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• An associate's degree from an accredited college or university with a major in health information technology/management.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Equivalent combinations of experience and education are qualifying.
• Certification: Must have one of the following:
• Apprentice/Associate Level Certification through AHIMA or AAPC.
• Mastery Level Certification through AHIMA or AAPC.
• Clinical Documentation Improvement Certification through AHIMA or ACDIS.

Grade Determinations

• Medical Records Technician (Coder) Auditor GS-09:
• One year of creditable experience equivalent to the journey grade level (GS-08).
• Mastery level certification through AHIMA or AAPC.
• Demonstrated Knowledge, Skills, and Abilities:
• Advanced knowledge of current coding classification systems.
• Ability to research and solve complex questions related to coding conventions.
• Ability to review coded data and supporting documentation.
• Ability to format and present audit results.
• Skill in interpersonal relations and conflict resolution.

Physical Requirements

See VA Directive and Handbook 5019.