Medical Records Technician (Coder) Auditor

Medical Records Technician (Coder) Auditor

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. Auditors serve as experts of current coding conventions and regulations related to professional and facility coding; perform audits of encounters to identify areas of non-compliance in coding; provide recommendations on appropriate coding; and are responsible for maintaining current knowledge of the various regulatory guidelines and requirements. Auditors work with staff to ensure that regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective action; perform prospective coding audits and utilize results to identify processing inadequacies and re-educate coding staff where necessary; and coordinate retrospective reviews to ensure adequate auditing of coding activities. Auditors act independently to plan, organize, direct and control areas with emphasis on data validation, analysis and generation of reports associated with the Medical Center's health information management program. This includes managing the professional health information management functions such as retrieving, reviewing and abstracting health record information. They also determine quality control measures needed; initiate and implement them by use of monitors and/or continuous review.

Duties of the Medical Record Technician (Coder) Auditor 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 of 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. Also 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 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 provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
• 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. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• 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.
• Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VISA and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes.

Work Schedule: 8am - 4:30pm, Monday through Friday

Telework: Not available.

Functional Statement #: 40407F

Relocation/Recruitment Incentives: Not authorized

Permanent Change of Station (PCS): Not authorized