Medical Records Technician (Coder) Auditor-Outpatient

Department of Veterans Affairs

This position is located within the Health Information Management (HIM) Service at the Salem VA Healthcare System (SVAHCS). The Medical Records Technician (Coder) Auditor is responsible for the accurate classification and coding of medical data derived from patient health records across hospital and physician-based settings, including private practices, group practices, multi-specialty clinics, and specialty care centers.

• The major duties of a Medical Records Technician (Coder) Auditor-Outpatient include, but are not limited to, the followings: Adheres to accepted coding practices, guidelines and conventions when validating the most appropriate diagnosis, operation and procedure 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 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, and proper sequencing Consults directly with the professional staff for clarification of conflicting or ambiguous clinical data Reviews 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 Audits accuracy and completeness of assigned codes, status and discharge disposition values Provides training and education to coding and clinical staff Work Schedule: Monday - Friday 8:00am - 4:30pm Remote: This position is currently eligible designated as for remote work and is operating under an extension to return-to-office requirement. That extension can be withdrawn at any time, at which point the employee may be required to return to the office within 50 miles of the Salem VA medical center. Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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