Medical Records Technician (Coder) Auditor

The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care you will operate in a model with three core elements seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veterans community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor Americas Veterans by providing exceptional health care that improves their health and well-being.

Major duties include but are not limited to:

• Complete and accurate diagnostic and procedural coded data are necessary for research epidemiology outcomes and statistical analysis financial and strategic planning reimbursement evaluation of quality of care and communication to support the patients treatment.
• Coders will follow current published ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting CPT Guidelines as well as other established industry standard coding guidance such as the American Medical Association (AMA) CPT Assistant and the American Hospital Associations (AHA) Coding Clinic.
• 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.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• 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 computer applications in day-to-day activities and duties such as Outlook Excel Word and Teams; competent in use of electronic health record applications as well as the encoder product suite.
• Reviews analyzes and reports performance monitors for inpatient outpatient VERA and Non-VA Medical Care (purchased care) coding.
• 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.
• Reviews coding and assist coders in improving coding accuracy.
• Facilitates improved overall quality completeness and accuracy of coded data.
• Responsible for performing audits of coded data developing criteria collecting data graphing trending and analyzing results creating reports and communicating in writing and/or in person to appropriate leadership and groups.
• Collaboratively works with coding staff and clinical staff to provide support and education on coding issues.
• Assists in the development of guidelines for data quality consistency and monitoring for compliance to improve the quality for clinical financial and administrative data to ensure that all coded data is fully documented and supported.
• Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

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

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( Effective May 7 2025 drivers licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the Required Documents section of this announcement.

As a condition of employment for accepting this position you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public determining if your employment advances the public interest we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period your employment will be terminated unless you receive certification in writing that your continued employment advances the public interest.

Basic Requirements:

• United States Citizenship: Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3 section A paragraph 3g this part.)
• Experience and Education
  • Experience. One year of creditable experience that indicates knowledge of medical terminology anatomy physiology pathophysiology medical coding and the structure and format of a health records. OR
  • Education. An associates degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g. courses in medical terminology anatomy and physiology medical coding and introduction to health records); OR
  • Completion of an AHIMA approved coding program or other intense coding training program of approximately one year or more that included courses in anatomy and physiology medical terminology basic ICD diagnostic/procedural and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor or comparable international accrediting authority at the time the program was completed; OR
  • Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
    • Six months of creditable experience that indicates knowledge of medical terminology general understanding of medical coding and the health record and one year above high school with a minimum of 6 semester hours of health information technology courses.
    • Successful completion of a course for medical technicians hospital corpsmen medical service specialists or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy physiology and health record techniques and procedures. Also requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
• Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) (2) or (3) below:
  (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
  (2) Mastery Level Certification through AHIMA or AAPC.
  (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  NOTE: Mastery level certification is required for all positions above the journey level.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations:

Medical Records Technician (Coder) Auditor GS-9

Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder).

Certification. Employees at this level must have a mastery level certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. Current mastery level certifications include: 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) Certified Inpatient Coder (CIC).

Demonstrated Knowledge Skills and Abilities. In addition to the experience above the candidate must demonstrate all of the following KSAs:
i. Advanced knowledge of current coding classification systems such as ICD CPT and HCPCS for the subspecialty being assigned (outpatient inpatient outpatient and inpatient combined).
ii. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
iii. Ability to review coded data and supporting documentation to identify adherence to applicable standards coding conventions and guidelines and documentation requirements.
iv. Ability to format and present audit results identify trends and provide guidance to improve accuracy.
v. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

Reference: For more information on this qualification standard please visit Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of evaluation or examination.