Medical Records Technician (Coder) Auditor

Summary This position is located in the Health Information Management (HIM) Section of the Health Administration Services Department at the Captain James A. Lovell Federal Health Care Center (FHCC) in North Chicago - IL. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting - and/or physician-based settings. These coding practitioners analyze and abstract patients' health records - and assign alpha-numeric codes for each diagnosis and procedure. 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 in accordance with VA PolicyExperience and Education ExperienceOne year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of a health recordsOR EducationAn 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 (e.g. - courses 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 codingThe 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 completedOR Experience/Education CombinationEquivalent combinations of creditable experience and education are qualifying for meeting the basic requirementsThe following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical 4 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 coursesSuccessful 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 proceduresAlso - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)CertificationPersons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) - (2) - or (3) belowNOTE: Mastery level certification is required for all positions above the journey levelhowever - for clinical documentation improvement specialist assignments - a clinical documentation improvement certification may be substituted for a mastery level certification: Apprentice/Associate Level Certification through AHIMA or AAPCMastery Level Certification through AHIMA or AAPCClinical Documentation Improvement Certification through AHIMA or ACDISEnglish Language ProficiencyMRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.7403(f) 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: Medical Records Technician (Coder) Auditor - GS-9 Auditor assignments can be established for any of the coder subspecialties (outpatient - inpatient - or outpatient and inpatient combined)The subspecialty will be reflected in the title - e.g. - MRT (Coder) Auditor (Outpatient)ExperienceOne year of creditable experience equivalent to the journey grade level of a MRT (Coder)CertificationEmployees at this level must have a mastery level certificationNOTE: See paragraph 2g for a detailed definition of mastery level certificationDemonstrated Knowledge - Skills - and AbilitiesIn addition to the experience above - the candidate 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 mannerAbility to review coded data and supporting documentation to identify adherence to applicable standards - coding conventions and guidelines - and documentation requirementsAbility to format and present audit results - identify trends - and provide guidance to improve accuracySkill in interpersonal relations and conflict resolution to deal with individuals at all organizational levelsMastery Level CertificationThis is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPCTo be acceptable for qualifications - the specific certification must represent a comprehensive competency in the occupationStand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualificationsCertification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodiesHowever - current mastery level certifications include: Certified Coding Specialist (CCS) - Certified Coding Specialist - Physician-based (CCS-P) - Registered Health Information Technician (RHIT) - Registered Health Information Administrator (RHIA) - Certified Professional Coder (CPC) - Certified Outpatient Coder (COC) - Certified Inpatient Coder (CIC)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. Duties Total Rewards of a Allied Health Professional Functions of this position include - but are not limited to the following: 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 selectionReviews assigned codes from the current version of several coding systems to include current versions of ICD - CPT - and/or HCPCSAdheres 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 codingMonitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services providedAssists facility staff with documentation requirements to completely and accurately reflect the patient care providedprovides technical support in the areas of regulations and policy - coding requirements - resident supervision - reimbursement - workload - accepted nomenclature - and proper sequencingAudits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes - MS-DRG - POA status - and discharge disposition values for inpatient health recordsReviews coding and assist coders in improving coding accuracyprovides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulationsinitiates various reports and analyzes dataPerforms audits of coded data - developing criteria - collecting data - graphing - trending - and analyzing results - creating reports - and communicating in writing and/or in person to appropriate leadership and groupsAnalyzes audit results and prepares summary feedback for individual coders and/or clinicians - making recommendations for improvementProvides coding consultation to coders and/or clinicians related to coding and documentation questionsMaintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices Work Schedule: Monday-Friday - 0730-1600 Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increasesWhen setting pay - a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade)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 experienceParental 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 childChild 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 $416.66Retirement: 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 telework available Virtual: This is not a virtual positionFunctional Statement #: 07790F Permanent Change of Station (PCS): Not Authorized