[Hiring] Supervisory Medical Records Technician @VA Northeast Ohio Healthcare System

Role Description

The VA Northeast Ohio Healthcare System is recruiting for a Supervisory Medical Records Technician. The Supervisory Medical Records Technician will function in the Health Information Management Systems section of Patient Care Administrative Service.

Responsibilities

• 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-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.

Qualifications

• 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:
  • One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
  • 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.
  • 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.
  • Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Persons hired or reassigned to the Supervisory MRT (Coder) positions in the GS-0675 series in VHA must have either:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• 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.

Benefits

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

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.