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Role Description

This position is located in the Health Information Management (HIM) section at the Kansas City VA Medical Center. MRTs (Coder) Auditors are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

• Perform all duties of a MRT (Coder)
• Serve as experts of current coding conventions and guidelines related to professional and facility coding
• Perform audits of encounters to identify areas of non-compliance in coding
• Facilitate improved overall quality, completeness, and accuracy of coded data
• Provide recommendations on appropriate coding
• Maintain current knowledge of various regulatory guidelines and requirements
• Assist facility staff with documentation requirements
• Provide technical support in regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing
• Consult with clinical staff for clarification of conflicting or ambiguous clinical data
• Use computer applications to produce reports, abstract records, and review assigned codes
• Perform prospective and retrospective coding audits
• Identify documentation and coding inadequacies and re-educate clinical and coding staff based on audit results
• Plan, organize, and perform auditing with emphasis on data validation, analysis, and report generation
• Assist in the development of guidelines for data quality, consistency, and monitoring for compliance
• Maintain statistical databases to track results and validate the program
• Identify patterns and variations in coding practices with regular reports to medical staff and management

Qualifications

• United States Citizenship
• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records
• Associate's degree from an accredited college or university in health information technology/management or related field with a minimum of 12 semester hours in relevant courses
• Completion of an AHIMA approved coding program or other intense coding training program
• Equivalent combinations of creditable experience and education are qualifying

Requirements

• Certification through AHIMA or AAPC (Apprentice/Associate Level, Mastery Level, or Clinical Documentation Improvement Certification)
• Mastery level certification required for positions above the journey level

Company Description