Medical Records Technician (Coder) Auditor (Outpatient)

This position, located in Health Information Management at Eastern Oklahoma VA Health Care System, involves coding and auditing patient records, ensuring coding accuracy and compliance. Candidates must be skilled in ICD, CPT, and HCPCS, and may provide coding education and conduct audits to improve data quality and documentation.

Complete all application requirements detailed in the "Required Documents" section of this announcement. Total Rewards of a VA Career: Total Rewards of a Allied Health Professional Code Assignment & Validation: Accurately reviews and assigns diagnostic and procedural codes using current versions of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS. Follows all official coding guidelines and industry standards (including AMA CPT Assistant and other established resources). Clinical Documentation Audit: Audits both inpatient and outpatient health records for completeness and accuracy of codes, MS-DRG, POA status, discharge disposition, E/M codes, and modifier usage. Evaluates clinical documentation to ensure optimal code assignment. Compliance & Education: Monitors regulatory, policy, and coding requirements for all services. Assists facility staff with documentation requirements, providing technical support, coding guidance, and education for clinical and coding staff to promote consistency and compliance. Conducts ongoing education and training to ensure accuracy and completeness of clinical information. Data Analysis & Reporting: Reviews, analyzes, and reports performance measures for inpatient, outpatient, VERA, and non-VA purchased care. Responsible for developing audit criteria, collecting and trending data, creating reports, and communicating findings to leadership and staff. Maintains statistical databases to track coding patterns and trends. Quality Assurance: Facilitates improvement of the quality, completeness, and accuracy of coded data. Assists in developing guidelines for data quality, consistency, and compliance to ensure accurate billing, reduce denials, and prevent fraud/abuse. Collaboration & Consultation: Consults directly with clinical staff for clarification of ambiguous or conflicting data. Collaborates cross-functionally to support education and process improvement related to coding. Provides advice and guidance as a technical expert in health information coding matters. Knowledge Application: Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, diagnostic tests, medications, procedures, and organizational principles to ensure proper code selection and documentation integrity. Additional: Must be proficient with computer applications such as Outlook, Excel, Word, Teams, electronic health records, and encoder product suites. Responsible for upholding all applicable standards, including VERA criteria and audit best practices. Must ensure all coded data in patient health records is fully supported and documented. Work Schedule: Full-time, Monday through Friday, 8:00 AM - 4:30 PM Pay: Competitive salary and regular salary increases Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year). Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Situational (Ad-hoc) as determined by agency policy Virtual: This is not a virtual position. Functional Statement #: 623-613770

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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's 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 interest. In 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.