Role Description The Dayton Ohio VA Medical Center's Health Information Management Service is recruiting for a well-qualified Medical Records Technician - Coder Auditor. - Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding. - Audits 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. - ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records. - Reviews coding and assists 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 analyzes 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 to provide support and education on coding issues; provides training and education to coding and clinical staff. - Researches complex coding issues and participates in process improvements related to coding. - Assists in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data. - As a technical expert in health information coding matters, provides advice and guidance on documentation and coding requirements. - Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines and audit standards, and results in appropriate data capture and reimbursement. - Analyzes audit results and prepares summary feedback for individual coders and/or clinicians, making recommendations for improvement. - Provides coding consultation to coders and/or clinicians related to coding and documentation questions. - Maintains statistical databases 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. Qualifications - 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: - One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records. - 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. - Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more. - Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. - Certification: - Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either: - Apprentice/Associate Level Certification through AHIMA or AAPC. - Mastery Level Certification through AHIMA or AAPC. - Clinical Documentation Improvement Certification through AHIMA or ACDIS. Requirements - One year of creditable experience equivalent to the journey grade level of a MRT (Coder). - Employees at this level must have a mastery level certification. - Demonstrated Knowledge, Skills, and Abilities: - Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned. - 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. Benefits - Competitive salary and regular salary increases. - 37-50 days of annual paid time off per year: - 13-26 days of annual leave. - 13 days of sick leave. - 11 paid Federal holidays per year. - 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. - 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. - Traditional federal pension - 5 years vesting - and federal 401K with up to 5% in contributions by VA. - Federal health/vision/dental/term life/long-term care insurance - many federal insurance programs can be carried into retirement.