Medical Records Technician (Coder) Auditor- (Outpatient and Inpatient)

<p>This position is located in the Health Information Management (HIM) section at the W.G. "Bill" Hefner VA Healthcare System. 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. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.</p><h3>Major Duties</h3><p>Announcement will close once 25 applicants is reached Major 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. 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 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. 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 inpatient, outpatient, VERA and Non-VA Medical Care (purchased care) coding. Audits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records. Audits accuracy and completeness of assigned of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment. 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. Performs other duties as assigned. Work Schedule: Monday - Friday, 8:00 to 4:30 pm Telework: Ad-Hoc only Virtual: This is not a virtual position. Functional Statement #: N/A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized</p><h3>Requirements</h3>You must be a U.S. Citizen to apply for this job. 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. 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/.