Medical Records Technician (Coder/Audit/Training)

Analyze patient medical records to identify inaccurately coded services in accordance with federal coding regulations and guidelines.

Assign specific codes to medical records, sequencing and determining codes to accurately reflect the resources and procedures used in the care of the patients.

Ensure compliance with regulatory and third-party insurance requirements in utilizing the ICD-10-CM, and CPT coding books.

Perform limited utilization review of outpatient and inpatient records to assure the diagnosis responsible for the length of stay is appropriately identified.

Assure secondary diagnoses are sequenced properly to assure maximum allocation under the Relative Value Unit (RVU) and Diagnosis-Related Group (DRG) systems.

Provide review and analysis of coding accuracy and compliance statistics, coordinating results with the Coding Manager and Patient Administration Department Head for feed back to the providers.

Prepare reports of findings and recommends staff education and training on accurate coding practices and compliance issues to maintain coding accuracy.

Provide monthly performance and progress reports addressing levels of accomplishment to Coding Manager and Patient Administration Department Head.

Maintain thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs.

Maintain a thorough understanding of medical record practices, standards, regulations, and Joint Commission requirements.

Perform diagnosis and procedure coding through application of International Classification of Diseases, Clinical Modification (ICD-11-CM) current edition and Current Procedural Terminology (CPT) coding guidelines.

Develop programs and plans for training medical and ancillary services staff in basic coding techniques and requirements.

Work in coordination with the government electronic health record sustainment trainer as appropriate and recommends coding resources to enhance data quality.

Who May Apply: US Citizens In order to qualify, you must meet the experience requirements described below.

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; religious; spiritual; community; student; social). You will receive credit for all qualifying experience, including volunteer experience.

Your resume must clearly describe your relevant experience; if qualifying based on education, your transcripts will be required as part of your application. Additional information about transcripts is in this document.

SPECIALIZED EXPERIENCE: One year of specialized experience which includes, 1) Assisting in auditing coders and/or providers to identify inaccurately coded services in accordance with coding regulations; 2) Identifying errors, trends, and/or concerns regarding diagnosis, Current Procedural Terminology (CPT), Evaluation and Management (E/M) errors and converting that data into training material; and 3) Providing guidance and functional knowledge to improve coding accuracy.

This definition of specialized experience is typical of work performed at the next lower grade/level position in the federal service (GS-06).