Supervisory Medical Records Technician

About the role

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.

What you will do

• 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.

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.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (***).
• 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.

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: ***

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: ***

How you will be evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC.

WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Areas of Consideration - Applicants will be considered based on the following areas of consideration.

First Area of Consideration (Facility Employees) - Current, permanent VA Northeast Ohio Healthcare System employees (this includes Outpatient Clinics, permanent employees of the Veteran Canteen Service assigned to this facility, Office of Information & Technology employees assigned to this facility, CPAC bargaining unit employees located at the Cleveland VAMC, and Virtual CBOPC bargaining unit employees under station 541 located at the Cleveland VAMC.

Second Area of Consideration (Other VA Employees) - Current, permanent Department of Veterans Affairs Employees (VA employees who are located at other VA medical centers). Third Area of Consideration - Current, permanent employees of other Federal agencies. Fourth Area of Consideration - All other qualified US citizens.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Documents you must provide

• Long-form resume/Curriculum vitae (CV) Mastery Level Coding Certification The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc. Cover Letter DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) License Long-form resume/Curriculum vitae (CV) Mastery Level Coding Certification Other (2) Other (3) Performance Appraisal Professional Certification Separation Notice (RIF) SF-15 SF-50/ Notification of Personnel Action Transcript

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.

After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service.

HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.

HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.

HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

Additional information

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions.

Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status.

VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

VA Healthcare System Serving Ohio, Indiana and Michigan (VISN 10) advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest.

As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community.

This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer.

For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.