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.
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
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.
Robert.Wheaton@va.gov · 317-988-0095
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $67970 – $88356/yr.
Yes, this position is fully remote.
Applications close on 2026-10-05.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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