Supervisory Medical Records Technician (CDIS)

U.S. Department of Veterans Affairs; Gary (IN); On-site; USD 70,000 - 100,000; Full time

Job summary

U.S. Department of Veterans Affairs in Loma Linda, CA, seeks a Supervisory Medical Records Technician (CDIS) to lead the HIM coding team and ensure accurate documentation in the electronic health record. The role involves concurrent and retrospective chart reviews and supervising staff to maintain coding quality.

On-site work is required; strong leadership and coding expertise are essential. The position emphasizes advanced knowledge of ICD, CPT, HCPCS coding, staff training, and coordination

Qualifications

• One year of creditable experience in medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure.
• Associate's degree with health information focus or AHIMA/AAPC certification in coding.
• Six months of related experience or education substitutions per VA standards.
• Certification showing mastery in coding or clinical documentation required (AHIMA or AAPC).

Responsibilities

• Adhere to coding guidelines to ensure accurate ICD, CPT, or HCPCS codes.
• Perform comprehensive reviews of patient health records to abstract data.
• Develop performance standards and conduct staff evaluations.
• Schedule work and monitor workflow to ensure timely completion.
• Train staff on encoder product suite and coding procedures.
• Coordinate with health record documentation and coding across units.

Skills

Supervisory duties

Coding knowledge (ICD/CPT/HCPCS)

Data analysis

Training skills

Interpersonal skills

Leadership

Education

Associate's degree in health information management/health information technology

AHIMA/AAPC certification or coding program completion

Tools

Encoder product suite

Job description

Summary

The Supervisory Medical Records Technician CDIS position is located in the Health Information Management (HIM) section at the Loma Linda VA Medical Center. They are skilled in classifying medical data from patient health records in the hospital - and/or physician-based settings - such as physician offices - group practices - multi-specialty clinics - and specialty centers. Work with clinical staff to ensure accurate documentation in the EHR. Will do concurrent and retrospective chart review - etc.

Qualifications

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy
• English Language Proficiency: MRTs (Coders) must be proficient in spoken and written English as required by 38 U.S. C
• 7403
• 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
• 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
• 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 experience:(a) 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.(b) 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)
• AND - Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1) - (2) - or (3)
• (1) Apprentice/Associate Level Certification through AHIMA or AAPC
• (2) Mastery Level Certification through AHIMA or AAPC
• (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS
• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria)
• Grade Determination: GS-10 Experience: In addition to the basic requirements - candidate must have one year of creditable experience equivalent to the next lower (GS-09) grade level
• AND - Certification: Employees at this level must have a Mastery Level Certification through AHIMA or AAPC or Clinical Documentation Improvement Certification through AHIMA or ACDIS
• This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC
• To be acceptable for qualifications - the specific certification must represent a comprehensive competency in the occupation
• Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications
• Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies
• 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) and Certified Inpatient Coder (CIC)
• Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist (CCDS)
• AND - Demonstrated Knowledge - Skills - and Abilities
• In addition to the experience above - the candidate must demonstrate ALL of the following KSAs: 1
• 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
• 2
• Advanced knowledge of current coding classification systems such as ICD - CPT - and HCPCS for the subspecialty being assigned (outpatient - inpatient - outpatient and inpatient combined)
• 3
• 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
• 4
• 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
• 5
• Leadership and managerial skills - including skill in interpersonal relations and conflict resolution to deal with employees - team leaders - and manager
• 6
• Ability to collect and analyze data - identify trends - and present results in various formats
• May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria)
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Physical Requirements: The position is primarily sedentary - with increased periods of bending - walking and stooping required
• The full performance level of this vacancy is GS-10.

Duties

• Adheres to accepted coding practices - guidelines and conventions when choosing the most appropriate diagnosis - operation - procedure - ancillary - or Evaluation and Management 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
• Performs a comprehensive review of the patient health record to abstract medical - surgical - ancillary - demographic - social - and administrative data to ensure complete data capture
• Develops performance standards and conducts performance evaluations for subordinate staff
• Schedules the sequence of work and operations on a weekly - monthly and quarterly basis to assure even workflow and distribution - expeditious handling of priorities and the meeting of deadlines
• Prepares workload and production reports
• reports on operations and problems encountered
• and presents proposed requests for resource needs based on past experience - anticipated staffing - equipment - and space
• Formulates and issues written instructions and procedures and special instructions for non-routine or complex assignments or to clarify published guides
• 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
• and coordinates - assigns - and monitors the workflow
• Keaps abreast of all regulations and guidelines governing the coding section - ensuring that staff supervised is educated as needed Coordinates with other Service representatives on matters concerning health record documentation and coding - as well as changes and challenges that may have an impact on other Units or Services
• Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities
• Required to train others on the encoder product suite
• Has constant interaction with health care providers evaluating and communicating with the expectation on improving health record documentation which will result in improved patient care and improved revenue generation
• Work Schedule: Monday - Friday 0730 - 1600 PST Telework: Not Available Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized
• Permanent Change of Station (PCS): Not Authorized