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Supervisory Medical Records Technician (CDIS-Outpatient and Inpatient)
Veterans Health Administration · Posted 70 days ago
Remote United States $68K – $88K Apply by Aug 4, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareFinanceTrades
Apply for this job → About the Role
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.
What You'll Do
- →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.
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.
- ✓Must pass pre-employment physical examination.
- ✓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.
- ✓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.
Personality Fit
Job ID: a7cf87a8-75ed-4336-8323-5e29f1b30dff
Posted via USAJobs