Supervisory Medical Records Technician (CDIS-Outpatient and Inpatient)

Summary

This position is assigned to the Health Administration Service, Health Information Management (HIM) section at the Richard L. Roudebush (RLR) VA. This position supervises a team which consists of Clinical Documentation Integrity Specialists (MRT CDIS) and MRT Auditors. Supervisory MRT (CDIS) must be able to perform all duties of a MRT CDIS (inpatient and outpatient) and MRT Auditor.

Duties

Responsible for reviewing the overall quality and completeness of clinical documentation. Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. 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 the organizational structure to ensure clinical documentation supports proper code selection. Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits. Adheres to accepted CDI practices, guidelines and conventions when reviewing health record documentation and providing feedback and training to clinical staff. Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding. Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity. Adheres to accepted coding practices, guidelines and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding. 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. Reviews VERA input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, SharePoint, and Teams; competent in use of electronic health record applications as well as the encoder and/or CDI product suite. Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation. 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. Collaboratively works with the professional clinical staff and provides support and education on documentation issues.. As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc. Compiles, reviews, abstracts, analyzes, and interprets medical data incidental to a variety of patient care and treatment activities. 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. The CDIS is expected to strive for the optimal payment to which the facility is legally entitled, but it is deemed unethical and illegal to maximize payment by means that contradict regulatory guidelines. Performs other duties included in the functional statement. Work Schedule: Monday - Friday, 8:00am to 4:30pm Remote: Anywhere in the U.S. (remote job) Position Title/Functional Statement #: Supervisory MRT (CDIS) / GS-675-10 #91504-0 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

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. 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. 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.

Qualifications and evaluation

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. NOTE: You must include qualifying specialized experience employment periods in mm/yyyy to mm/yyyy format on your resume and indicate Full-Time or Part-Time (if Part-time, must include # of hours worked per week). AND, if you have held a Government position, that position's grade level MUST be listed on your resume; Failure to include all requirements in your resume will result in disqualification. Please refer to USAJOBS Help Center - What should I include in my federal resume? for additional information on resume requirements. 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. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. 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.

Education

MPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. 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: http://ope.ed.gov/accreditation/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Assignment: For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Supervisory MRTs (Coder) are responsible for supervising coding staff at the facility level. Supervisory MRTs (Coder) must be able to perform all duties of a MRT (Coder). The supervisory coder is responsible for the supervision, administrative management, and direction of coding staff. They are responsible for program management of a coding section/unit to ensure performance monitors are established and met. They perform a full range of supervisory responsibilities, to include evaluating the performance of subordinate staff, approving sick and annual leave requests, identifying educational or training needs, resolving employee complaints, and taking disciplinary actions, when necessary. They inform higher level management of anticipated vacancies or increases in workload. They recommend employees for promotions, reassignments, recognitions, retention or release of probationary employees, or other changes of assigned personnel. They make decisions on the selection of employees for vacant or new positions. They serve as an expert coding resource to ensure accuracy and integrity of all coding. They collaborate with revenue, compliance, and other departments to support coding accuracy that is consistent with the official guidelines for coding and reporting. They resolve claim edits referred to coding management and monitor reports for outstanding services, rejects, or uncoded episodes of care for inpatients and/or outpatients. The supervisory coder ensures claim denials related to coding errors are resolved, and/or daily coding rejects are corrected for accurate billing and data collection. They provide education to clinical and coding staff. They assess current audit findings and evaluate impact to coding and documentation practices. They oversee the reporting of coding and documentation audit results to leadership. They collect and prepare data for studies involving inpatient stays and outpatient encounters for clinical evaluation purposes, prepare and maintain a variety of complex records and daily, monthly, or "on demand" reports, as requested. The supervisory coder creates and monitors outpatient reports, inpatient case mix reports, top DRGs, and key performance indicators to identify patterns, trends, and variations. They investigate and evaluate potential causes for changes or problems and collaborate with the appropriate staff to effect resolution or explain variances. They participate in the formulation of objectives and strategies utilizing coded data to support goals for patient care, teaching, research, and optimizing management of resources. Supervisory MRTs whose assignments involve two or more MRT specialty areas will be assigned the parenthetical title for the predominant specialty area. Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment.

How to apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 10/05/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/13072546. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date. To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.

Required documents

To apply for this position, you must provide a complete Application Package which includes: Professional Certification Resume Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field. Upload your Most recent SF-50 if you are a current or former Federal Employee. The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please 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 (Schedule A) Disability Letter (VA) License Other (1) Other (2) Other (3) Performance Appraisal Professional Certification Resume Separation Notice (RIF) SF-15 SF-50/ Notification of Personnel Action Transcript Veterans' Preference: Although Hybrid Title 38 occupations follow Title 5 Veterans' preference rules, as required by the Merit Systems Protection Board (Graves v. A, 117 M.S.P.R. 697 (2012)), 38 U.S.C. § 7412 waives the requirement to apply Veterans' preference to external applicants for appointments made during the fiscal year to hybrid title 38 occupations reported among the occupations with the largest staffing shortages. This announcement occupation(s) is reported to be among the largest staffing shortages. Veterans preference does not apply to this job announcement per the Veterans Access, Choice and Accountability Act of 2014 (PL 113-146, dated August 7, 2014) Therefore, Veteran's Preference will not be applied to this posting's applicant scores and selection process.

Additional information

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. 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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act. Whole Health Statement VA Healthcare System Serving Ohio, Indiana and Michigan (VISN 10) advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.