Medical Records Technician (Coder) Auditor-Outpatient

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 in accordance with VA Policy. English Language Proficiency: Proficient in spoken and written English as required by 38 U.S.C. § 7403(f). And 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 a health records. OR, Education: An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, 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. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses. (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification: Mastery Level Certification through AHIMA or AAPC. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to the Basic Requirements above and certification, candidates must also meet any additional requirements to include KSAs and experience based on grade assignment below. GS-09 Experience: One year of creditable experience equivalent to the GS-08 grade level with identifying areas of non-compliance in coding; facilitating improved overall quality, completeness, and accuracy of coded data; and re-educating clinical and coding staff on audit results. And Demonstrated KSAs: In addition to the experience above, the employee must demonstrate all of the following KSAs: Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). 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. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-9. Physical Requirements: See VA Directive and Handbook 5019. This position is located within the Health Information Management (HIM) Service at the Salem VA Healthcare System (SVAHCS). The Medical Records Technician (Coder) Auditor is responsible for the accurate classification and coding of medical data derived from patient health records across hospital and physician-based settings, including private practices, group practices, multi-specialty clinics, and specialty care centers.

• The major duties of a Medical Records Technician (Coder) Auditor-Outpatient include, but are not limited to, the followings: Adheres to accepted coding practices, guidelines and conventions when validating the most appropriate diagnosis, operation and procedure 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 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, and proper sequencing Consults directly with the professional staff for clarification of conflicting or ambiguous clinical data Reviews 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 Audits accuracy and completeness of assigned codes, status and discharge disposition values Provides training and education to coding and clinical staff Work Schedule: Monday - Friday 8:00am - 4:30pm Remote: This position is currently eligible designated as for remote work and is operating under an extension to return-to-office requirement. That extension can be withdrawn at any time, at which point the employee may be required to return to the office within 50 miles of the Salem VA medical center. Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized