This position is in the Health Information Management (HIM) section at the Northern Arizona VA Medical Center. MRT (Coder) Auditor's 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.
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: Citizenship. Citizen of the United States. 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: 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. 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: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. 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: GS-9 Medical Records Technician (Coder) Auditor Experience. 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. Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Auditors must be able to perform all duties of a MRT (Coder). Auditors serve as experts of current coding conventions and guidelines related to professional and facility coding. Auditors perform audits of encounters to identify areas of non-compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data. They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. They assist facility staff with documentation requirements to completely and accurately reflect the patient care provided. They provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data. They use computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. They perform prospective and retrospective coding audits and use results to identify documentation, coding inadequacies, and re-educate clinical and coding staff based on audit results. They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports. They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data. They ensure that all coded data is fully documented and supported. They maintain statistical database(s) to track the results and validate the program. They identify patterns and variations in coding practices with regular reports to the medical staff and management. 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. 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-09. The actual grade at which an applicant may be selected for this vacancy is a GS-09. Physical Requirements: The work is primarily sedentary with prolonged periods of sitting. The work requires moderate lifting, carrying, pushing, standing; reaching above shoulder; use of fingers; ability to read without strain; ability to hear the whispered voice with or without hearing aid; emotional & mental stability.
Major duties include, but are not limited to: Utilize computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. Perform audits of encounters to identify areas of noncompliance in coding. Facilitate improved overall quality, completeness, and accuracy of coded data. Works with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective action. 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. 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. 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. 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. 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. Work Schedule: Monday - Friday, 07:30 am to 04:00 pm. Virtual: This is not a virtual position. Functional Statement #: 00000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized