Medical Records Technician (Coder) Auditor

Department of Veterans Affairs

The Medical Records Technician (Coder) Auditor position is located in the Health Information Management (HIM) section at the San Diego VA Medical Center. 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.

• The GS-09 Medical Records Technician (Coder) Auditor position is above the journey level and duties include but are not limited to: 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. 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. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. 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. 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. 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. 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. Work Schedule: Monday-Friday, 0700-1800 Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Telework: This position is currently telework eligible but may be subject to return to the office mandate. Virtual/Remote: This is considered a remote position; not a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized

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