Medical Records Technician (Coder) Auditor- (Outpatient and Inpatient)

Job Title

Help

Major 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.
• Reviews assigned codes from the current version of several coding systems to include current versions of ICD, CPT, and/or HCPCS.
• Adheres to accepted coding practices, guidelines and conventions when validating the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. 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 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.
• 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 inpatient, outpatient, VERA and Non-VA Medical Care (purchased care) coding.
• Audits accuracy and completeness of assigned ICD-10-CM and ICD-10-PCS codes, MS-DRG, POA status, and discharge disposition values for inpatient health records. Audits accuracy and completeness of assigned of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment.
• As a technical expert in health information coding matters, provides advice and guidance on documentation and coding requirements. Maintains current knowledge to ensure that coding and documentation meets regulatory guidelines, audit standards, and results in appropriate data capture and reimbursement.
• Analyzes audit results and prepares summary feedback for individual coders and/or clinicians, making recommendations for improvement. Provides coding consultation to coders and/or clinicians related to coding and documentation questions.
• Performs other duties as assigned.

Work Schedule: Monday - Friday, 8:00 to 4:30 pm

Telework: Ad-Hoc only

Virtual: This is not a virtual position.

Functional Statement #: N/A

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized