U.S. Department of Veterans Affairs
MEDICAL RECORDS TECH (CODER) AUDITOR
U.S. Department of Veterans Affairs, Salem, Virginia, us, 24155
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MEDICAL RECORDS TECH (CODER) AUDITOR
role at
U.S. Department of Veterans Affairs
Summary This position is located in the Health Information Management (HIM) section at the Salem VA Medical Center. The auditor classifies medical data from patient health records in hospital, physician office, group practice, multi‑specialty clinic, and specialty center settings.
Work Schedule 8:00 am–4:30 pm, Monday–Friday | Onsite location | Telework not authorized
Responsibilities
Provides technical support in regulations, policy, coding requirements, resident supervision, reimbursement, workload, nomenclature, and sequencing.
Consults with clinical staff to clarify conflicting or ambiguous clinical data.
Applies comprehensive knowledge of terminology, anatomy, physiology, disease processes, treatment modalities, procedural codes, and best practices to ensure proper code selection.
Reviews assigned codes from ICD‑10, PCS, CPT, and HCPCS.
Adheres to accepted coding practices, guidelines, and conventions for diagnosis, procedure, ancillary, or E/M codes.
Applies guidelines for VERA program coding categories.
Monitors regulatory and policy changes affecting coded information for VAMC services and maintains compliance.
Assists facility staff with documentation requirements to reflect patient care accurately.
Expertly searches patient records to justify code assignments.
Reviews, analyzes, and reports performance monitors for PCE.
Audits accurate assignment of ICD‑10‑CM, PCS, CPT, HCPCS, and modifiers for inpatient/outpatient records.
Provides coding guidance and initiates reports to improve coding accuracy.
Facilitates improved overall quality, completeness, and accuracy of coded data.
Performs coding audits, develops criteria, collects data, graphing, analyzing results, and creating reports.
Collaborates with coding staff and clinical staff to provide education on coding issues and training.
Assists in developing guidelines for data quality, consistency, and compliance.
Provides advice and guidance on documentation and coding requirements.
Analyzes audit results and prepares summary feedback for coders and clinicians.
Uses computer applications (Outlook, Excel, Word, Access) and health record systems (VistA, CPRS).
Requirements Conditions of employment:
U.S. citizen
Selective Service registration (males born after 12/31/1959)
Proficient spoken and written English
May serve a trial period
Background/security investigation subject
Complete online onboarding; acceptable ID required (driver’s license or state ID must be REAL ID compliant)
Participation in seasonal influenza vaccination program required for VA Health Care Personnel
Complete all application requirements in the "Required Documents" section
Qualifications (Basic Requirements)
U.S. citizenship
English language proficiency (spoken and written)
Experience and Education (One year of creditable experience or an associate’s degree in health information technology/management, or a related degree, or completion of an AHIMA‑approved coding program of at least one year that led to coding certification). Equivalent combinations of creditable experience and education are also qualifying.
Certification Mastery Level Certification through AHIMA or AAPC is required for this occupation. Acceptable 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)
Grade Determinations and Assignments: Auditors must perform all duties of an MRT (Coder) (Outpatient and Inpatient). Auditors serve as experts in current coding conventions and guidelines. Auditors perform audits of encounters to identify areas of non‑compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data. They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the regulatory guidelines and requirements. They assist facility staff with documentation requirements to reflect patient care accurately. They provide technical support in regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They directly consult with clinical staff for clarification of conflicting or ambiguous clinical data. They use computer applications to produce a wide range of reports, abstract records, and review assigned codes. They perform prospective and retrospective coding audits and use results to identify documentation, coding inadequacies, and re‑educate clinical and coding staff based on audit results. They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports. They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data. They ensure that all coded data is fully documented and supported. They maintain statistical database(s) to track the results and validate the program. They identify patterns and variations in coding practices with regular reports to the medical staff and management.
Demonstrated Knowledge, Skills, And Abilities (KSAs)
Advanced knowledge of current outpatient coding classification systems such as ICD, CPT, and HCPCS
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
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
Preferred Experience: Outpatient/Inpatient coding experience
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MEDICAL RECORDS TECH (CODER) AUDITOR
role at
U.S. Department of Veterans Affairs
Summary This position is located in the Health Information Management (HIM) section at the Salem VA Medical Center. The auditor classifies medical data from patient health records in hospital, physician office, group practice, multi‑specialty clinic, and specialty center settings.
Work Schedule 8:00 am–4:30 pm, Monday–Friday | Onsite location | Telework not authorized
Responsibilities
Provides technical support in regulations, policy, coding requirements, resident supervision, reimbursement, workload, nomenclature, and sequencing.
Consults with clinical staff to clarify conflicting or ambiguous clinical data.
Applies comprehensive knowledge of terminology, anatomy, physiology, disease processes, treatment modalities, procedural codes, and best practices to ensure proper code selection.
Reviews assigned codes from ICD‑10, PCS, CPT, and HCPCS.
Adheres to accepted coding practices, guidelines, and conventions for diagnosis, procedure, ancillary, or E/M codes.
Applies guidelines for VERA program coding categories.
Monitors regulatory and policy changes affecting coded information for VAMC services and maintains compliance.
Assists facility staff with documentation requirements to reflect patient care accurately.
Expertly searches patient records to justify code assignments.
Reviews, analyzes, and reports performance monitors for PCE.
Audits accurate assignment of ICD‑10‑CM, PCS, CPT, HCPCS, and modifiers for inpatient/outpatient records.
Provides coding guidance and initiates reports to improve coding accuracy.
Facilitates improved overall quality, completeness, and accuracy of coded data.
Performs coding audits, develops criteria, collects data, graphing, analyzing results, and creating reports.
Collaborates with coding staff and clinical staff to provide education on coding issues and training.
Assists in developing guidelines for data quality, consistency, and compliance.
Provides advice and guidance on documentation and coding requirements.
Analyzes audit results and prepares summary feedback for coders and clinicians.
Uses computer applications (Outlook, Excel, Word, Access) and health record systems (VistA, CPRS).
Requirements Conditions of employment:
U.S. citizen
Selective Service registration (males born after 12/31/1959)
Proficient spoken and written English
May serve a trial period
Background/security investigation subject
Complete online onboarding; acceptable ID required (driver’s license or state ID must be REAL ID compliant)
Participation in seasonal influenza vaccination program required for VA Health Care Personnel
Complete all application requirements in the "Required Documents" section
Qualifications (Basic Requirements)
U.S. citizenship
English language proficiency (spoken and written)
Experience and Education (One year of creditable experience or an associate’s degree in health information technology/management, or a related degree, or completion of an AHIMA‑approved coding program of at least one year that led to coding certification). Equivalent combinations of creditable experience and education are also qualifying.
Certification Mastery Level Certification through AHIMA or AAPC is required for this occupation. Acceptable 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)
Grade Determinations and Assignments: Auditors must perform all duties of an MRT (Coder) (Outpatient and Inpatient). Auditors serve as experts in current coding conventions and guidelines. Auditors perform audits of encounters to identify areas of non‑compliance in coding. They facilitate improved overall quality, completeness, and accuracy of coded data. They provide recommendations on appropriate coding and are responsible for maintaining current knowledge of the regulatory guidelines and requirements. They assist facility staff with documentation requirements to reflect patient care accurately. They provide technical support in regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. They directly consult with clinical staff for clarification of conflicting or ambiguous clinical data. They use computer applications to produce a wide range of reports, abstract records, and review assigned codes. They perform prospective and retrospective coding audits and use results to identify documentation, coding inadequacies, and re‑educate clinical and coding staff based on audit results. They act independently to plan, organize, and perform auditing with emphasis on data validation, analysis, and generation of reports. They assist in the development of guidelines for data quality, consistency, and monitoring for compliance to improve the quality of clinical, financial, and administrative data. They ensure that all coded data is fully documented and supported. They maintain statistical database(s) to track the results and validate the program. They identify patterns and variations in coding practices with regular reports to the medical staff and management.
Demonstrated Knowledge, Skills, And Abilities (KSAs)
Advanced knowledge of current outpatient coding classification systems such as ICD, CPT, and HCPCS
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
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
Preferred Experience: Outpatient/Inpatient coding experience
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