Supervisory Medical Records Technician

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

01Basic Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - Experience and Education: Must meet one of the following: (1) 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, (2) 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, (3) 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, (4) 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).

02Certification

Persons hired or reassigned to the Supervisory MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (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.

NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification. IN ADDITION TO MEETING THE BASIC REQUIREMENTS LISTED ABOVE, YOU MUST MEET THE SPECIALIZED EXPERIENCE AT THE GS-10 LEVEL TO QUALIFY FOR THIS POSITION.

GS-10 Grade Determinations: Experience: One year of creditable experience equivalent to the next lower grade level GS-9.

03Certification

Employees at this level must have a mastery level certification. 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. - Responsible for program management of a coding section/unit to ensure performance monitors are established and met. - Performs 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. - Inform higher level management of anticipated vacancies or increases in workload. - Recommend employees for promotions, reassignments, recognitions, retention or release of probationary employees, or changes of personnel. - Make decisions on the selection of employees for vacant positions. - Serves as an expert coding resource to ensure accuracy and integrity of coding. - Collaborates with revenue, compliance, and other departments to support coding accuracy consistent with official guidelines for coding and reporting. - Resolves claim edits referred to coding management and monitor reports for outstanding services, rejects, or uncoded episodes of care for inpatients and/or outpatients. - Ensures claim denials related to coding errors are resolved, and/or daily coding rejects are corrected for accurate billing and data collection. - Provides education to clinical and coding staff.

They assess current audit findings and evaluate impact to coding and documentation practices. - Oversees the reporting of coding and documentation audit results to leadership. - Collects 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 monitor outpatient reports, inpatient case mix reports, top DRGs, and key performance indicators to identify patterns, trends, and variations, investigate potential causes for changes or problems, and take appropriate steps, in collaboration with staff, to effect resolution or explain variances. - Participates in the formulation of objectives and strategies using coded data to support goals for patient care, teaching, research, and optimizing management of resources.

AND Demonstrated Knowledge, Skills, and Abilities: 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). - Ability to provide or coordinate staff development and training. - 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.

Physical Requirements. The work is primarily sedentary. Physical demands do not exceed those of a typical office setting. There may be some walking, standing, twisting, turning, sitting, pushing, bending, repetitive keyboarding, or carrying of light items. See VA Directive and Handbook 5019, Employee Occupational Health Service

Duties - Applies knowledge of medical terminology, anatomy and physiology, disease processes, treatments, diagnostics, medications, procedures, health services, and organizational structure to ensure accurate code selection. - Selects and assigns current ICD, CPT, and HCPCS codes per accepted guidelines, conventions, and ethical practices for inpatient and outpatient services. - Applies diagnosis, procedure, ancillary, and Evaluation and Management (E/M) codes, including Veterans Equitable Resource Allocation (VERA) classification criteria. - Monitors regulatory, policy, and coding changes affecting VAMC services and ensures timely compliance to maintain accurate facility databases and support cost-recovery programs. - Reviews electronic health records and abstracts medical, surgical, ancillary, demographic, social, and administrative data for facility profiling, resource and budget planning, accreditation and peer review, billing, reimbursement, and research. - Reviews documentation to ensure diagnoses and procedures are supported; consults providers to resolve conflicting or ambiguous information and reports inaccurate documentation or coding. - Advises clinical and administrative staff on documentation, coding, regulations, reimbursement, workload, nomenclature, sequencing, resident supervision, and related requirements. - Uses electronic health records, encoder applications, Outlook, Excel, Word, Teams, and other tools for coding, auditing, reporting, and data management. - Works effectively in teams, supports organizational goals and deadlines, manages priorities, and adapts to changing workloads and projects.

Supervisory/Operational Functions - Provides daily oversight of coding operations, including staffing adjustments, workflow resolution, coder support, turnaround monitoring, action plans, escalation, and regulatory compliance. - Establishes performance standards; evaluates staff; monitors productivity, accuracy, and compliance; and addresses performance issues through coaching, training, awards, or discipline. - Interviews and recommends candidates; approves leave; supports EEO requirements; communicates management goals; and addresses employee concerns. - Plans and adjusts weekly, monthly, and quarterly schedules and assignments to balance workload, staffing, priorities, deadlines, productivity, and employee capabilities. - Distributes work equitably, monitors progress, assigns tasks based on complexity and resources, and revises operations to improve efficiency, productivity, and employee satisfaction. - Prepares workload, production, and operational reports; identifies problems; and recommends staffing, equipment, space, and resource needs. - Provides written and on-the-job instruction, reference materials, and technical guidance for routine, complex, and non-routine assignments. - Trains new coders, students, professional staff, and administrative personnel in coding, abstracting, electronic health records, encoder systems, ICD and CPT maintenance, and unit operations. - Reviews coding, audits work, analyzes reports and data, identifies training needs, and provides guidance to improve accuracy, consistency, productivity, and compliance. - Keeps current with coding regulations, policies, guidelines, and conventions and ensures staff receive needed education. - Participates in technical evaluations and health record validation for Joint Commission, Centers for Medicare & Medicaid Services (CMS), and health record documentation compliance.

Coordination, Documentation, and Reimbursement - Coordinates with clinical, administrative, CDI, charge, and other service representatives on documentation, coding changes, workflow challenges, and cross-service impacts. - Promotes collaboration among coders, CDI, providers, and charge services to support complete, accurate coding. - Assists with coding-related claims denials, insurance denial reviews, trend identification, appeals, and targeted education tools. - Analyzes and recommends documentation-system improvements to optimize patient care data, VERA workload, third-party reimbursement, and resource management. - Reviews compliance monitoring results, productivity and accuracy reports, billing rejects, and spot checks to identify individual and program[1]wide training needs. - Trains providers through feedback, email queries, informal meetings, and orientation to improve documentation, patient care, coding accuracy, and revenue generation. - Orients house staff, students, and affiliated health information or medical record technology trainees to coding, abstracting, health record systems, and unit operations.

Work Schedule: Monday - Friday 8:00AM - 4:30pm Compressed/Flexible: At supervisor's discretion Virtual: This is a virtual position. Position Description/PD#: 95438 Relocation/Recruitment Incentives: Not authorized. Critical Skills Incentive (CSI): Not authorized. Permanent Change of Station (PCS): Not authorized.