Supervisory Medical Records Technician (CDIS)

U.S. Department of Veterans Affairs; Bay Pines (FL); On-site; USD 65,000 - 90,000; Full time

Job summary

U.S. Department of Veterans Affairs, Bay Pines VA Healthcare System, seeks a Medical Records Technician (MRT, Coder) to classify medical data from patient health records within HIM. The role requires mastery of medical terminology, coding knowledge, and AHIMA/AAPC certifications.

Duties include ensuring accurate documentation, coding, and data reporting across inpatient and outpatient settings. The position emphasizes training, compliance with VA standards, and collaboration with clinical staff

Qualifications

• Experience and knowledge of medical terminology, anatomy, physiology and coding basics.
• Education options: associate degree in HIM or AHIMA coding program or equivalent.
• Candidates may qualify via education/experience combinations and must pursue coding certification.
• Certification options include CCS, CCS-P, RHIT, RHIA, CPC, COC, CIC and related clinical documentation credentials.

Responsibilities

• Facilitate improved health record documentation quality, accuracy, and completeness.
• Educate clinical and coding staff to enhance documentation practices.
• Identify opportunities for documentation improvement to ensure accurate coding and resource utilization.
• Prepare and maintain reports and data useful for performance monitoring and studies.

Skills

Medical terminology

Anatomy

Physiology

Pathophysiology

Medical coding

Health records

Education

Associate degree in health information technology / health information management

AHIMA coding program completion

Experience/education combination

Certification readiness (e.g., CCS, RHIT, RHIA, CPC)

Job description

Summary

This position is located in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). MRTs (Coder) 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.

Qualifications

Basic Requirements:

• Citizenship
• Citizen of the United States
• (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA policy)
• English Language Proficiency
• MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
• 7403(f)
• Experience and Education Experience
• One year of creditable experience that indicates knowledge of medical terminology - anatomy - physiology - pathophysiology - medical coding - and the structure and format of a health records
• OR - Education
• An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management - or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g. - courses in medical terminology - anatomy and physiology - medical coding - and introduction to health records)
• OR - Completion of an AHIMA approved coding program - or other intense coding training program of approximately one year or more that included courses in anatomy and physiology - medical terminology - basic ICD diagnostic/procedural - and basic CPT coding
• The training program must have led to eligibility for coding certification/certification examination - and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor - or comparable international accrediting authority at the time the program was completed
• OR - Experience/Education Combination
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements
• The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology - general understanding of medical coding and the health record - and one year above high school - with a minimum of 6 semester hours of health information technology courses
• 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 health record techniques and procedures
• Also - requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder)
• ***CERTIFICATION: Applicants at this level must have Mastery Level certification: Mastery Level Certification through AHIMA or AAPC
• Current mastery level certifications include: Certified Coding Specialist (CCS) - Certified Coding Specialist - Physician-based (CCS-P) - Registered Health Information Technician (RHIT) - Registered Health Information Administrator (RHIA) - Certified Professional Coder (CPC) - Certified Outpatient Coder (COC) - Certified Inpatient Coder (CIC)
• Clinical Documentation Improvement Certification through AHIMA or ACDIS
• Grandfathering Provision
• All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title - series - and grade held - including positive education and certification that are part of the basic requirements of the occupation
• For employees who do not meet all the basic requirements in this standard - but who met the qualifications applicable to the position at the time they were appointed to it - the following provisions apply: Such employees may be reassigned - promoted up to and including the journey level - or changed to lower grade within the occupation - but will not be promoted beyond the journey level or placed in supervisory or managerial positions
• Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels
• MRTs who are appointed on a temporary basis - prior to the effective date of the qualification standard - may not have their temporary appointment extended - or be reappointed on a temporary or permanent basis - until they fully meet the basic requirements of the standard
• MRTs initially grandfathered into this occupation - who subsequently obtain additional education that meets all the basic requirements of this qualification standard - must maintain the required credentials as a condition of employment in the occupation
• Employees who are retained as a MRT under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry as a MRT Grade Determinations: Specialized Experience - MRT (CDIS) GS-10 Experience
• One year of experience equivalent to the next lower grade level - GS-09 and have a current Mastery Level Certification
• Experience include - but not limited to: Reviews health record documentation - develop criteria - collect data - graph and analyze results - create reports - and communicate orally and/or in writing to appropriate groups and leadership
• Experience developing and implementing active training/education programs (i.e. - seminars - workshops - short courses - informational briefings - and conferences) for all clinical staff
• Serves as a liaison between health information management and clinical staff
• Recommending changes and/or update medical center policy pertaining to clinical documentation improvement
• Provide training in small or large groups - educating clinical staff
• Demonstrated Knowledge - Skills - and Abilities (KSAs) - MRT (CDIS-Outpatient and Inpatient) GS-10 In addition to the experience above - the candidate must demonstrate all of the following KSAs: Ability to perform a full range of supervisory duties - to include recommending awards - approving leave - evaluating work - resolving staff issues - and assigning - planning - and coordinating work to ensure duties are completed in an accurate and timely fashion
• Advanced knowledge of current coding classification systems such as ICD - CPT - and HCPCS for the subspecialty being assigned (outpatient - inpatient - outpatient and inpatient combined)
• Advanced knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC) - MS-DRG structure - POA indicators - severity of illness - risk of mortality - complexity of care for inpatients - and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type - setting of service - and level of E/M service provided for outpatients
• Skill in training methods and teaching skills sufficient to conduct continuing education for staff development and training on topics related to clinical documentation integrity and improvement issues
• Leadership and managerial skills - including skill in interpersonal relations and conflict resolution to deal with employees - team leaders - and managers
• Ability to collect and analyze data - identify trends - and present results in various formats
• KSA's MUST BE CLEARLY REPRESENTED IN YOUR RESUME TO BE FOUND QUALIFIED
• WE WILL NOT MAKE ASSUMPTIONS ABOUT YOUR EXPERIENCE
• References: VA Handbook 5005/122 Part II - Appendix G-57
• For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements
• See VA Directive and Handbook 5019 - Employee Occupational Health Service.

Duties

• Total Rewards of a Allied Health Professional Primary duties of the Supervisory Medical Record Technician include but not limited to: Responsible for facilitating improved overall quality - education - completeness and accuracy of health record documentation through extensive interaction with clinical - coding - and other associated staff to ensure clinical documentation supports services rendered to patients - appropriate workload is captured - and resources are properly allocated
• Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity - accurately address all acute and chronic conditions - and reflect the true health status of patients
• Responsible for management of the CDI unit to ensure performance monitors are established and met
• Recommend employees for promotions - reassignments - recognitions - retention or release of probationary employees - or other changes of assigned personnel
• Provide education to clinical and coding staff
• 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
• Creates and monitors outpatient reports - inpatient case mix reports - top ORGs - and key performance indicators to identify patterns - trends - and variations
• Review documentation and identify documentation opportunities to the health record to ensure accurate severity of illness - risk of mortality - complexity of care - and utilization of resources
• Work Schedule: Monday thru Friday 8:00am to 4:30pm Telework: Not Authorized Virtual: This is not a virtual position
• Functional Statement #: 22087F Relocation/Recruitment Incentives: Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized