Medical Records Technician (Coder) Auditor (Outpatient)

Complete all application requirements detailed in the "Required Documents" section of this announcement. Total Rewards of a VA Career: Total Rewards of a Allied Health Professional Code Assignment & Validation: Accurately reviews and assigns diagnostic and procedural codes using current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS.

Follows all official coding guidelines and industry standards (including AMA CPT Assistant and other established resources). Clinical Documentation Audit: Audits both inpatient and outpatient health records for completeness and accuracy of codes, MS-DRG, POA status, discharge disposition, E/M codes, and modifier usage.

Evaluates clinical documentation to ensure optimal code assignment. Compliance & Education: Monitors regulatory, policy, and coding requirements for all services. Assists facility staff with documentation requirements, providing technical support, coding guidance, and education for clinical and coding staff to promote consistency and compliance.

Conducts ongoing education and training to ensure accuracy and completeness of clinical information. Data Analysis & Reporting: Reviews, analyzes, and reports performance measures for inpatient, outpatient, VERA, and non-VA purchased care.

Responsible for developing audit criteria, collecting and trending data, creating reports, and communicating findings to leadership and staff. Maintains statistical databases to track coding patterns and trends. Quality Assurance: Facilitates improvement of the quality, completeness, and accuracy of coded data.

Assists in developing guidelines for data quality, consistency, and compliance to ensure accurate billing, reduce denials, and prevent fraud/abuse. Collaboration & Consultation: Consults directly with clinical staff for clarification of ambiguous or conflicting data.

Collaborates cross-functionally to support education and process improvement related to coding. Provides advice and guidance as a technical expert in health information coding matters.

Knowledge Application: Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, diagnostic tests, medications, procedures, and organizational principles to ensure proper code selection and documentation integrity.

Additional: Must be proficient with computer applications such as Outlook, Excel, Word, Teams, electronic health records, and encoder product suites. Responsible for upholding all applicable standards, including VERA criteria and audit best practices. Must ensure all coded data in patient health records is fully supported and documented.

Work Schedule: Full-time, Monday through Friday, 8:00 AM - 4:30 PM Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).

Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: 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.

Child Care Subsidy: 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.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Situational (Ad-hoc) as determined by agency policy Virtual: This is not a virtual position.

Functional Statement #: 623-613770

Complete all application requirements detailed in the "Required Documents" section of this announcement. BASIC REQUIREMENTS: a. Citizenship: Must be a citizen of the United States. (Non-citizens may be appointed only when qualified U.S. citizens are unavailable, per chapter 3, section A, paragraph 3g.) b.

Experience and Education: Applicants must meet one of the following: Experience: One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.

OR Education: Associate's degree from an accredited college or university (recognized by the U.S.

Department of Education) in health information technology/health information management, or a related degree with at least 12 semester hours in health information technology/management (e.g., medical terminology, anatomy and physiology, medical coding, health records courses).

OR AHIMA-Approved Coding Program: Completion of an AHIMA-approved or equivalent in-depth coding program of approximately one year or more, including anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding courses.

The program must have led to coding certification eligibility, and the sponsoring institution must have been accredited by a U.S. Department of Education-accredited (or comparable international) accreditor when completed. OR Equivalent Combination of Experience and Education Acceptable combinations include: a.

Six months of creditable experience (see above) plus one year above high school (minimum of 6 semester hours of health information technology courses). b. Completion of medical technician/hospital corpsmen/medical service specialist/hospital training programs given by the Armed Forces or U.S.

Maritime Service, including anatomy, physiology, and health record techniques. This may be substituted on a month-for-month basis for up to six months of experience, plus an additional six months of creditable experience (paid or unpaid, equivalent to a MRT [Coder]). c.

Certification: Mastery-Level Certification through AHIMA or AAPC A mastery level certification is recognized as an advanced credential in health information management or medical coding.

This designation is limited to certifications obtained through either the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

In order to qualify as a mastery level certification, the credential must demonstrate comprehensive competency across the occupation, rather than focusing on a single specialty area. Stand-alone specialty certifications do not meet this standard and therefore are not acceptable for qualification purposes.

It is important to note that certification titles may evolve over time, and certifying bodies may update the list of accepted mastery-level certifications.

As of now, the following certifications are considered mastery level: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), and Certified Inpatient Coder (CIC).

Note: Mastery level certification is required for all positions above journey level; clinical documentation improvement certification may substitute for mastery certification in relevant assignments.

GRADE DETERMINATIONS - In addition to the basic requirements, you must also meet the following criteria for the specified grade levels: Medical Records Technician (Coder) Auditor, GS-9 Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder).

Certification: Mastery level certification required (see Basic Requirements section for accepted certifications). Demonstrated Knowledge, Skills, and Abilities (KSAs): Candidates must demonstrate all the following: Advanced knowledge of coding classification systems (ICD, CPT, HCPCS) for the relevant subspecialty.

Ability to research and resolve complex coding convention/guideline questions promptly and accurately. Ability to review coded data/supporting documents for compliance with standards and documentation requirements. Ability to format and present audit results, identify trends, and provide improvement guidance.

Skill in interpersonal relations and conflict resolution across all organizational levels.

Preferred Experience: At least 5 years of production outpatient coding experience, comprised of primary care and multiple specialties, preferably in a hospital setting, as a certified coder Experience conducting outpatient encounter coding audits Performed leadership role over small coding teams to optimized performance Reviewed data sets and performing analytical assessment in deducing trends and adverse findings Development of action plans to correct or improve coding performance Providing training and education to both providers and coders, including development of training products and conducting group and one-on-one briefs on the material; demonstrated proficiency in spreadsheets such as Microsoft Excel and presentation software such as Microsoft Power Point Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

This vacancy is above the full performance level. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.