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MEDICAL RECORDS TECH (CODER) Auditor Inpatient/Outpatient
Veterans Health Administration · Posted 10 days ago
Hybrid Fayetteville, NC $64K – $84K Apply by Jun 29, 2026 Medical Records Technician ESTJISFJISTJ HealthcareFinance
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) section at the Fayetteville VA NC Coastal Health Care System. MRT Auditors are skilled in classifying medical data from inpatient/outpatient health records in the hospital setting, and/or physician-based settings, such as physician offices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis & procedure.
What You'll Do
- →Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
- →They directly consult with the clinical staff for clarification of conflicting or ambiguous clinical data.
- →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 organizational structure to ensure proper code selection.
- →Reviews assigned codes from the current version of several coding systems to include current versions of the ICD-10, PCS, Current Procedural Terminology (CPT), and/or HCPCS.
- →Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
- →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.
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
- →Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
- →Expertly searches patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
- →Reviews, analyzes and reports performance monitors for PCE.
- →Audit accurate and complete assignment of ICD-10-CM, PCS, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for inpatient/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.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
- ✓Applicants who refuse to be tested will be denied employment with VA.
- ✓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.
- ✓Must pass pre-employment physical examination.
- ✓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.
Personality Fit
Job ID: 069a8cee-58dd-46f5-bfd4-c593e0e7667d
Posted via USAJobs
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