Medical Records Technician (Coder Auditor)

US Department of Veterans Affairs    Augusta, GA
Job Description



    This position is located in the Health Information Management Section (HIMS) at the Charlie Norwood VA Medical Center Downtown or Uptown Division. The Medical Records Technician (Coder Auditor) is responsible for abstracting medical record data and assigning codes using different clinical classification systems appropriate for the type of care provided. Serve as experts of current coding conventions and regulations related to professional and facility coding.


    Major duties include, but are not limited to the following:

    • Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care {purchased care) coding.
    • 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.
    • Facilitates improved overall quality, completeness and accuracy of coded data. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
    • Responsible for performing audits of coded data, developing criteria, collecting data, graphing 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 and provides 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. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center s authorized reimbursement for utilization of resources provided.
    • Provides advice and guidance on documentation and coding requirements.
    • 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; 8:00am-4:30pm
    Position Title/#: Medical Records Technician (Coder) Auditor/F00812
    Telework Eligible: No
    Financial Disclosure Report: Not required
    Relocation Expenses: Relocation expenses are not authorized for this position.

    Travel Required

    Occasional travel - Travel between divisions as needed

    Supervisory status


    Promotion Potential


  • Job family (Series)

    0675 Medical Records Technician

  • Requirements


    Conditions of Employment

    • Review/Approval by professional standards board (PSB)
    • You must be a U.S. Citizen to apply for this job
    • Designated and/or random drug testing may be required
    • Selective Service Registration is required for males born after 12/31/1959
    • You may be required to serve a probationary period
    • Subject to a background/security investigation
    • Must be proficient in written and spoken English
    • Selected applicants will be required to complete an online onboarding process
    • Pre-employment physical required


    To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 12/13/2019.
    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 must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
    • Experience and Education
      (1) Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.
      (2) Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).
      (3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:

      (a) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses.

      (b) 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.
    Preferred Experience: Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines;- Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators;- Knowledge of severity of illness and risk of mortality indicators; and- Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The

    Grade Determinations:

    GS-9 MRT (Coder) Auditor

    (a) Experience. One year of experience equivalent to the next lower grade level. Examples of experience includes, but are not limited to the following: Analyzing the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation; Reviews, analyzes and reports performance monitors for PTF, PCE, VERA and Non-VA Medical Care (purchased care) coding; 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; 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); 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.

    (b) Demonstrated KSAs. In addition to the basic requirements and the specialized experience above, the candidate must demonstrate the following KSAs:
    1. Knowledge of the applicable regulatory guidelines and requirements for current coding conventions.
    2. Knowledge of coding classification systems.
    3. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions, and documentation requirements.
    4. Ability to format and present results and provide guidance to improve accuracy.

    (c) Assignment. Auditors serve as experts of current coding conventions and regulations related to professional and facility coding. Auditors 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. Coordinate retrospective reviews to ensure adequate auditing of coding activities. 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. Determine quality control measures needed; initiate and implement them by use of monitors and/or continuous review.

    References: VA HR Handbook 5005/79, Part II, Appendix G35

    Physical Requirements: May include but not limited to standing up to two hours per day, use of both hands, use of fingers, and sitting up to eight hours per day; light lifting and carrying, under 15 pounds; repetitive computer use.


    IMPORTANT: Education cannot be substituted for the one (1) year of specialized experience.

    Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit:

    Additional information

    This job opportunity announcement may be used to fill additional vacancies.

    It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

    This position is in the Excepted Service and does not confer competitive status.

    VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

    Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

    If you are unable to apply online view the following link for information regarding an Alternate Application.

    How You Will Be Evaluated

    You will be evaluated for this job based on how well you meet the qualifications above.

    IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

    NOTE: The Professional Standards Board (a peer-review group) will review the selected candidate s education and experience and recommend the grade and salary at which the candidate will be placed. For internal selectees eligible for promotion, the board will recommend grade and HR will determine step in accordance with policy.

    Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

    Background checks and security clearance

    Security clearance

    Not Required

    Drug test required


    Position sensitivity and risk

    Non-sensitive (NS)/Low Risk

    Trust determination process


  • Required Documents

    Required Documents

    To apply for this position, you must provide a complete Application Package which includes:

    • Resume

    SF 50(s) - Required if Current of Former Federal employee - More than one SF-50 may be required
    Current Federal Employees
    - You must submit your most recent 2019 SF-50 proving your current federal employment status. (It cannot be an award SF-50).
    - You must submit a SF-50(s) that shows you have completed (1- year) at the next lower grade. (SF-50 showing step increase or promotion will normally suffice).
    • You can obtain a copy from your electronic Official Personnel File (eOPF) at
    FORMER Federal Employees
    - You must submit your separation SF-50 from federal service.
    - You must submit a SF-50(s) that shows you have completed (1- year) at the next lower grade. (SF-50 showing step increase will normally suffice).

    VA Form 10-2850c - Application for Associated Health Occupationscan be found at: (Required if selected)

    The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50 s (current/former Federal employees), etc.

    • Cover Letter
    • DD-214/ Statement of Service
    • Disability Letter (VA)
    • VA form 10-2850c
    • Other (2)
    • Professional Certification
    • Resume
    • SF-15
    • SF-50/ Notification of Personnel Action
    • Transcript

    Veterans Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 Application for 10 Point Veteran Preference with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans Preference, please visit

    If you are relying on your education to meet qualification requirements:

    Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

    Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

  • Benefits


    A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits.

    Review our benefits

    Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.

Tue, 10 Dec 2019 17:11:13 GMT

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