Supervisory Medical Records Technician (CDIS)

Veterans Health Administration • Bay Pines, FL

6d • Onsite

About The Position

This position is in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System. Medical Records Technicians (Coders) classify medical data from patient health records in hospital and physician-based settings. The Supervisory Medical Records Technician (CDIS) manages the Clinical Documentation Improvement (CDI) unit and works with clinical, coding, and related staff to improve the quality, completeness, and accuracy of health record documentation. The position is responsible for ensuring documentation supports services rendered, appropriate workload is captured, and resources are allocated properly.

The role identifies documentation improvement opportunities and ensures diagnoses and procedures are documented at the highest appropriate level of specificity, accurately reflect acute and chronic conditions, and represent patients’ health status. The incumbent establishes and monitors unit performance measures, provides education to clinical and coding staff, and prepares and maintains data, records, and reports for clinical evaluation and performance monitoring. The position also supervises staff and exercises personnel-management responsibilities.

The work schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is not authorized, and the position is not virtual. Relocation/recruitment incentives are authorized. Permanent Change of Station and PCS Appraised Value Offer are not authorized.

Requirements

• U.S. citizenship, subject to the stated exception under VA policy when qualified citizens cannot be recruited.
• Proficiency in spoken and written English.
• One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health-record structure and format; or qualifying education, coding training, or an eligible combination of education and experience.
• Current Mastery Level certification through AHIMA or AAPC. Listed examples include CCS, CCS-P, RHIT, RHIA, CPC, COC, and CIC.
• Clinical Documentation Improvement certification through AHIMA or ACDIS.
• For GS-10, one year of experience equivalent to GS-09 and current Mastery Level Certification.
• Experience reviewing health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating findings orally or in writing to appropriate groups and leadership.
• Experience developing and implementing active training or education programs for clinical staff and serving as a liaison between health information management and clinical staff.
• Ability to perform a full range of supervisory duties, including recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work.
• Advanced knowledge of applicable coding classification systems, including ICD, CPT, and HCPCS.
• Advanced knowledge of CC/MCC, MS-DRG structure, POA indicators, severity of illness, risk of mortality, and complexity of care for inpatients, and CPT Evaluation and Management criteria for outpatient coding.
• Skill in training methods and teaching sufficient to conduct continuing education for staff development on clinical documentation integrity and improvement.
• Leadership, managerial, interpersonal, and conflict-resolution skills for working with employees, team leaders, and managers.
• Ability to collect and analyze data, identify trends, and present results in various formats.
• Must meet applicable background/security investigation and onboarding requirements and participate in the VA seasonal influenza vaccination program.
• Must complete the application requirements in the announcement’s Required Documents section.
• Must serve a one- or two-year trial period, subject to evaluation and written certification for continued employment.
• Education used to qualify must be recognized by the U.S. Department of Education and from an accredited institution; foreign education requires a Certificate of Foreign Equivalency and transcript.
• The required KSAs must be clearly represented in the applicant’s resume.

Responsibilities

• Facilitate improvements in the quality, education, completeness, and accuracy of health record documentation through interaction with clinical, coding, and associated staff.
• Ensure clinical documentation supports services rendered to patients, appropriate workload capture, and proper allocation of resources.
• Identify documentation improvement opportunities and ensure diagnoses and procedures are documented to the highest level of specificity, accurately address acute and chronic conditions, and reflect patients’ health status.
• Manage the CDI unit and establish and monitor performance measures.
• Recommend personnel actions, including promotions, reassignments, recognition, retention or release of probationary employees, and other changes to assigned personnel.
• Provide education to clinical and coding staff, including training on clinical documentation integrity and improvement.
• Collect and prepare data for studies involving inpatient stays and outpatient encounters for clinical evaluation.
• Prepare and maintain complex records and daily, monthly, and on-demand reports.
• Create and monitor outpatient reports, inpatient case-mix reports, top ORGs, and key performance indicators to identify patterns, trends, and variations.
• Review health record documentation and identify opportunities to improve accuracy regarding severity of illness, risk of mortality, complexity of care, and resource utilization.
• Perform supervisory duties, including recommending awards, approving leave, evaluating work, resolving staff issues, and assigning, planning, and coordinating work to ensure timely and accurate completion.

Benefits

• Federal employee benefits package for employees and their families, with eligibility dependent on position type.
• Potential credit toward annual leave accrual based on prior work or military service, subject to request and approval before appointment.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree