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Medical Records Tech (Coder) Auditor - Sioux Falls, SD #7879818

Company: US Department of Veterans Affairs

Date: 04/10/2021

City: Sioux Falls, SD

Salary: 53433 USD / year

Employment type: Full-time

Duties


Summary



This position is located in the Health Information Management (HIM) section at the Sioux Falls VA HCS. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.





Responsibilities




  • 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.
  • 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. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) 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 provided by the VAMC. 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 window based 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. Ensures current versions of all software applications are loaded and functional after any updates or changes.
  • 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.
  • As a technical expert in health information coding matters, 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.
Work Schedule: Mon-Fri 08:00 - 4:30 This is not a virtual position
Financial Disclosure Report: Not required



Travel Required


Not required





Supervisory status

No




Promotion Potential

9





  • Job family (Series)


    0675 Medical Records Technician



    Similar jobs


    • Coders, Health Information
    • Health Information Coders
    • Health Information Technicians
    • Medical Records And Health Information Technicians
    • Medical Records Technicians
    • Technicians, Health Information

  • Requirements



    Requirements


    Conditions of Employment


    • You must be a U.S. Citizen to apply for this job
    • Designated and/or random drug testing may be required
    • Selective Service Registration is required for males born after 12/31/1959
    • You may be required to serve a probationary period
    • Subject to a background/security investigation
    • Must be proficient in written and spoken English
    • Selected applicants will be required to complete an online onboarding process

    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.
    • Experience and Education: (1) 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,
    • (2) 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,
    • (3) 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,
    • (4) 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: Employees at this level must have a mastery level certification through AHIMA or AAPC.
    GS-9 Grade Determinations:

    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.


    In addition to the experience above, the candidate must demonstrate all of the following Knowledge, Skills, and Abilities.(KSAs):

    i. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined).

    ii. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.

    iii. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements.

    iv. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy.

    v. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

    References: VA Handbook 5005-122 Part II Appendix G57
    Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.



    Education


    IMPORTANT: 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 information



    Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.


    This 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.







    How You Will Be Evaluated



    You will be evaluated for this job based on how well you meet the qualifications above.


    IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.


    Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.





    Background checks and security clearance




    Security clearance

    Other




    Drug test required

    No






    Position sensitivity and risk

    Non-sensitive (NS)/Low Risk




    Trust determination process

    Suitability/Fitness







  • Required Documents



    Required Documents



    To apply for this position, you must provide a complete Application Package which includes:


    • VA Form 10-2850c Application signed within the last year
    • Professional Certification
    • Resume


    VA Form 10-2850c Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search.


    The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

    • Cover Letter
    • DD-214/ Statement of Service
    • Disability Letter (Schedule A)
    • Disability Letter (VA)
    • License
    • OF-306
    • VA Form 10-2850c Application signed within the last year
    • PCS Orders
    • Performance Appraisal
    • Professional Certification
    • Proof of Enrollment
    • Proof of Marriage Status
    • Resume
    • Separation Notice (RIF)
    • SF-15
    • SF-50/ Notification of Personnel Action
    • Transcript

    Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx.



    If you are relying on your education to meet qualification requirements:


    Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.


    Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.





  • Benefits



    Benefits



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    Review our benefits


    Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.







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    U.S. citizens, nationals or those who owe allegiance to the U.S.



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