Medical Records Technician (Coder) Auditor

About the role

The Medical Record Technician (Coder) Auditor position is located in the Health Information Management (HIM) section at the Thomas H. Corey VA Medical Center. Medical Record Technician (Coder) Auditors hold a mastery level certification, able to perform all duties of a MRT (Coder), and serve as experts of medical coding conventions and guidelines related to professional and facility coding.

Responsibilities

• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles of practices of health services and the organizational structure to ensure proper code selection.
• Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management code to ensure ethical, accurate, and complete coding.
• Maintains current knowledge of the various regulatory guidelines and requirements related to professional and facility coding.
• Audits encounters to identify areas of non-compliance in coding and provides recommendations on appropriate coding.
• Works with staff to ensure that regulations are met or identifies areas of weakness and reports them to appropriate supervisors for corrective action.
• Performs prospective coding audits and utilizes results to identify processing inadequacies and re-educates coding staff where necessary.
• Coordinates retrospective reviews to ensure adequate auditing of coding activities.
• Acts independently to plan, organize, direct and control areas with emphasis on data validation, analysis, and report generation associated with the Medical Center's health information management program.
• Retrieves, reviews, and abstracts health record information to determine quality control measures needed.
• Initiates and implements quality control measures by using monitors and/or continuous review.

Requirements

This posting is open to all current, permanent VHA Nationwide employees. Veteran preference is waived for this position for the fiscal year 2026.

PLEASE NOTE: This Medical Records Technician (Coder) Auditor position is not remote and requires physical presence on-site.

Qualifications

• One year of creditable experience that indicates knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles of practices of health services and the organizational structure to ensure proper code selection.
• One year of creditable experience equivalent to the journey grade level of a MRT (Coder).
• Certification: Employees at this level must have a mastery level certification.