MEDICAL RECORDS TECH (CODER) Auditor Inpatient/Outpatient

<p>This position is located in the Health Information Management (HIM) section at the Fayetteville VA NC Coastal Health Care System. MRT Auditors are skilled in classifying medical data from inpatient/outpatient health records in the hospital setting, and/or physician-based settings, such as physician offices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis & procedure.</p><h3>Major Duties</h3><p>Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data. 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 organizational structure to ensure proper code selection. Reviews assigned codes from the current version of several coding systems to include current versions of the ICD-10, PCS, Current Procedural Terminology (CPT), and/or 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. Expertly searches 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 PCE. Audit accurate and complete assignment of ICD-10-CM, PCS, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for inpatient/outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment. Reviews coding and assist 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. 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. Collaboratively works with coding staff and clinical staff to provide support and education on coding issues. Provides training and education to coding and clinical staff. Researches complex coding issues and participates in process improvements related to coding. Assists 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. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided. Work Schedule: Monday - Friday from 8:00AM - 4:30PM est. 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)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) Telework: Ad-hoc Virtual: This is not a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized</p><h3>Requirements</h3>You must be a U.S. Citizen to apply for this job. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.<h3>Education</h3>Note: 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. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.