Medical Record Technician Auditor

Summary
This position is in the Health Information Management (HIM) section at the Atlanta VA Medical Center. 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.

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 Policy
• English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C.
• 7403(f)
• Experience a) One year of creditable experience equivalent to the journey grade level of a MRT (Coder)
• b) Demonstrated KSAs
• In addition to the experience above - the employee must demonstrate all the following KSAs: (1) Advanced knowledge of current coding classification systems such as ICD - CPT - and HCPCS for the subspecialty being assigned (outpatient - inpatient - outpatient and inpatient combined)
• (2) Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner
• (3) Ability to review coded data and supporting documentation to identify adherence to applicable standards - coding conventions and guidelines - and documentation requirements
• (4) Ability to format and present audit results - identify trends - and provide guidance to improve accuracy
• and (5) Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels
• Certification Employees at this level must have a mastery level certification
• 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)
• d) Loss of Credential
• Following initial certification - credentials must be maintained through rigorous continuing education - ensuring the highest level of competency for employers and consumers
• An employee in this occupation who fails to maintain the required certification must be removed from the occupation - which may result in termination of employment
• Reference: VA HANDBOOK PART II - APPENDIX G57
• The full performance level of this vacancy is GS-9. The actual grade at which an applicant may be selected for this vacancy is GS-9. 5
• CUSTOMER SERVICE: Responds to the needs of customers while supporting the VA mission
• communicates and treats customers in a courteous - tactful - and respectful manner
• Constructively and appropriately handles conflicts with customer
• 3
• FUNCTIONS: Reviews - analyzes - and reports performance monitors for PTF - PCE - VERA and Non-VA Medical Care (purchased care) coding
• Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes - MS-DRG - POA status - and discharge disposition values for inpatient health records
• Audit accurate and complete assignment 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
• 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 assignments
• Performance is evaluated in terms of quality of service rendered
• effectiveness in achieving the objectives of the HIM program
• and in meeting statutory - regulatory - and agency requirements
• Physical Requirements: The work is mostly sedentary
• however - some bending - stretching - walking - carrying less than 15 pounds and using a computer terminal are required
• No special physical characteristics or special physical abilities are required.

Duties

• Major duties 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 selection
• Reviews assigned 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 (E/M) code to ensure ethical - accurate - and complete coding
• Reviews - analyzes and reports performance monitors for PTF - PCE - VERA and Non-VA Medical Care (purchased care) coding
• Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes - MS-DRG - POA status - and discharge disposition values for inpatient health records
• Audit accurate and complete assignment 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
• 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
• Work Schedule: Monday - Friday 8:00AM-4:30PM or 7:00AM a-3:30PM Telework: Yes - Reg Teleworks 6+ Days/PP Functional Statement #: 54540F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized This is a remote opportunity
• Organization is currently included on the Return to Office (RTO) mid-term exemption list (180-days)
• Remote work is currently authorized
• however - candidates may be subject to return to office in the event policy changes or the exemption is not extended.