[Hiring] Medical Records Technician (Coder) Auditor @Royal C Johnson Veterans Memorial Hospital

Role Description

This position is located in the Health Information Management (HIM) section at the Sioux Falls VA Medical Center. 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.

• Temporarily eligible for Remote work within 50 miles of a VA Medical Center.
• May fall under the Presidential Memorandum titled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review.
• Total Rewards of an Allied Health Professional.

Duties may include but are not limited to the following:

• Complete and accurate diagnostic and procedural coded data are necessary for research, epidemiology, outcomes and statistical analysis, financial and strategic planning, reimbursement, evaluation of quality of care, and communication to support the patient's treatment.
• Diagnoses and procedures will be coded utilizing the current edition of International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Apply 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 ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines and conventions when validating 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.
• Assist 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.
• Reviews, analyzes and reports performance monitors for inpatient, outpatient, VERA and Non-VA Medical Care (purchased care) 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.
• 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.
• Provides ongoing education to all members of the patient care team.
• As a technical expert in health information coding matters, provides advice and guidance on documentation and coding requirements.
• Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines, audit standards, and results in appropriate data capture and reimbursement.
• Analyzes audit results and prepares summary feedback for individual coders and/or clinicians, making recommendations for improvement.
• Provides coding consultation to coders and/or clinicians related to coding and documentation questions.

Work Schedule

• Monday-Friday 8:00am to 4:30pm

Pay

• Competitive salary and regular salary increases

Paid Time Off

• 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
• Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

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).

Education Requirements

Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment.

Qualifications

• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records; OR
• 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.

Certification

• 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.

Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service.

English Language Proficiency

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

Grade Determinations

• Medical Records Technician (Coder) Auditor, GS-9.
• One year of creditable experience equivalent to the journey grade level of a MRT (Coder) (GS-8).
• Employees at this level must have a mastery level certification.