Medical Records Technician; Coder Auditor

Position: Medical Records Technician (Coder) Auditor
The Medical Records Technician (Coder) Auditor is located in the Health Information Management (HIM) section of Medical Administration Service at the VA Maryland Health Care System. A Medical Records Technician must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), the Healthcare Common Procedure Coding System (HCPCS) and be skilled in classifying medical data from patient health records.

Total Rewards of a Allied Health Professional

Duties:

* 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.

* 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.

* Provides timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.

* 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, accepted nomenclature, and proper sequencing.

* Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.

* Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.

* Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.

* 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, MSDRG, 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.

* 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.

Work Schedule:

Monday-Friday,8:00am-4:30pm

Compressed/Flexible:

Not Authorized

Recruitment Incentive (Sign-on Bonus):
Not Authorized

Permanent Change of Station (Relocation Assistance):
Not Authorized

Pay:
Competitive salary and regular salary increases. When 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 experience.

Parental 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 child.

Child 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 $416.66.

Retirement:
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…