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Medical Records Technician (Coder) Auditor

Company: Veterans Affairs, Veterans Health Administration
Location: Columbia
Posted on: February 16, 2020

Job Description:

SummaryThis position is located in the Health Information Management (HIM) section at the Columbia VA Health Care System. The Medical Records Technician (Coder) Auditor is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.ResponsibilitiesAuditors serve as experts of current coding conventions and regulations related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. Provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. Auditors work with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective action. Perform prospective coding audits and utilize results to identify processing inadequacies and re-educate coding staff where necessary. Coordinate retrospective reviews to ensure adequate auditing of coding activities. Act independently to plan, organize, direct and control areas with emphasis on data validation, analysis and generation of reports associated with the Medical Center's health information management program. This includes managing the professional health information management functions such as retrieving, reviewing and abstracting health record information. Determine quality control measures needed; initiate and implement them by use of monitors and/or continuous review. Specific duties include but are not limited to: Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding. 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 and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis. Responsible for performing audits of coded data, developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Collaboratively works with coding staff and clinical staff and provides support and education on coding issues. Assists in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all coded data is fully documented and supported. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided. Provides advice and guidance on documentation and coding requirements. Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management. Performs other duties as assigned. Work Schedule: Monday - Friday, 8:00am - 4:30pm (subject to change based on agency needs)Financial Disclosure Report: Not requiredRequirementsConditions of EmploymentQualificationsTo qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/14/2020.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. 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 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 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. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC. (2) Mastery Level Certification through AHIMA or AAPC. (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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). Grade Determinations: Applicants must meet both the basic requirements above and grade determinants below:GS-9 Medical Records Technician (Coder) Auditor Experience. One year of creditable experience equivalent to the journey level of a MRT (Coder) 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). Demonstrated Knowledge, Skills, and Abilities. In 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 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. References: VA Handbook 5005/122, Part II, Appendix G57 - Medical Records Technician Qualification Standard. 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. Physical Requirements: Work is primarily sedentary but requires use of fingers for typing on a keyboard for a pc, etc. May require light lifting and carrying (under 15 pounds) and reaching above shoulder.EducationIMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.Additional InformationThis job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members. If you are unable to apply online view the following link for information regarding an Alternate Application.

Keywords: Veterans Affairs, Veterans Health Administration, Columbia , Medical Records Technician (Coder) Auditor, Accounting, Auditing , Columbia, South Carolina

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