Medical Records Technician (Coder) Auditor

Total Rewards of a Allied Health Professional

• 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 the International Classification of Diseases (ICD) Current Procedural Terminology (CPT) and/or Healthcare Common Procedure Coding System (HCPCS).
• 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.
• Reviews analyzes and reports performance monitors for PTF PCE VERA and Non-VA Medical Care (purchased care) coding.
• Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes MSDRG POA status and discharge disposition values for inpatient health records.
• Audit accurate and complete assignment 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.
• Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data.
• Collaboratively works with coding staff and clinical staff to provide support and education on coding issues. Provides training and education to coding and clinical staff. Researches complex coding issues and participates in process improvements related tocoding.
• Analyze audit results and prepare summary feedback for individual coders and/or clinicians making recommendations for improvement.
• 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.

• 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.
• Must pass pre-employment physical evaluation.
• 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.

• 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.

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).
• 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:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
    • NOTE: Mastery level certification is required for all positions above the journey level; however or clinical documentation improvement specialist assignments a clinical documentation improvement certification may be substituted for a mastery level certification.
• Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title series and grade held including positive education and certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard but who met the qualifications applicable to the position at the time they were appointed to it the following provisions apply:
  • Such employees may be reassigned promoted up to and including the journey level or changed to lower grade within the occupation but will not be promoted beyond the journey level or placed in supervisory or managerial positions.
  • Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels.
  • MRTs who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended or be reappointed on a temporary or permanent basis until they fully meet the basic requirements of the standard.
  • MRTs initially grandfathered into this occupation who subsequently obtain additional education that meets all the basic requirements of this qualification standard must maintain the required credentials as a condition of employment in the occupation.
  • Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT.

• Experience. One year of creditable experience equivalent to the journey grade level (GS-08) of a MRT (Coder).
• Certification. Employees at this level must have a mastery level certification.
  • 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:
  • Advanced knowledge of current coding classification systems such as ICD CPT and HCPCS for the subspecialty being assigned (outpatient inpatient outpatient and inpatient combined).
  • Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner.
  • Ability to review coded data and supporting documentation to identify adherence to applicable standards coding conventions and guidelines and documentation requirements.
  • Ability to format and present audit results identify trends and provide guidance to improve accuracy.
  • Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels.

• At least three years of coding and/or coding audit experience with working knowledge of the coding guidelines conventions and regulatory requirements for both inpatient and outpatient settings.
• Knowledge of inpatient coding guidelines and requirements including ICD-10-CM and ICD-10-PCS MS-DRG assignment Present on Admission (POA) status and discharge disposition values.
• Knowledge of outpatient/professional coding guidelines and requirements including ICD-10-CM CPT and HCPCS Evaluation and Management (E/M) level selection and modifier usage.
• Experience reviewing and evaluating clinical documentation to determine whether it supports accurate complete and compliant code assignment.
• Experience developing and delivering presentations training or educational sessions to coding and/or clinical (provider) staff.