Supervisory Medical Records Technician (Clinical Documentation Improvement/CDIS)

Quick Facts

• Role: Supervisory Medical Records Technician (Clinical Documentation Improvement/CDIS)
• Schedule: Monday–Friday, 07:30–16:00 PST
• Telework: Not available
• Work mode: On-site (not virtual)

Description

The Supervisory Medical Records Technician (CDIS) leads clinical documentation coding and medical record review work to ensure accurate and complete documentation in the EHR. The role includes concurrent and retrospective chart reviews, monitoring regulatory and policy changes, supervising and training coding staff, and providing guidance to improve coding accuracy and compliance.

Responsibilities

• Use accepted coding practices and guidelines to assign appropriate diagnosis, procedure, ancillary, and Evaluation & Management (E/M) codes
• Abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture
• Monitor and interpret changing regulatory and policy requirements impacting coded services
• Review coding work and assist coders in improving accuracy; provide coding guidance to ensure consistent compliance
• Develop performance standards, evaluate staff, and coordinate workflow to ensure accurate and timely completion
• Schedule and sequence work to meet weekly/monthly/quarterly deadlines; adjust priorities day-to-day
• Prepare workload and production reports, report issues, and propose resource needs based on trends
• Issue written instructions and procedures for non-routine/complex coding assignments
• Train others on the encoder product suite and provide continuing education on documentation integrity and improvement
• Coordinate with other service representatives on health record documentation and coding changes

Requirements

• U.S. citizenship
• Proficiency in written and spoken English
• Subject to background/security investigation
• Complete all required application steps, including an online assessment
• Selective Service Registration required for eligible males
• Complete online onboarding and pre-employment identification requirements
• Seasonal influenza vaccination program participation is required
• Serve a 1–2 year trial period with fitness/public interest evaluation

Qualifications

• Experience or accredited education/training indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure/format
• MRT (Coder) certification via AHIMA or AAPC (Apprentice/Associate or Mastery) OR Clinical Documentation Improvement certification via AHIMA/ACDIS
• For GS-10: Mastery-level certification via AHIMA/AAPC or CDIS certification via AHIMA/ACDIS plus qualifying GS-09-equivalent experience
• Demonstrated KSAs: supervisory leadership, advanced ICD/CPT/HCPCS knowledge, CC/MCC and MS-DRG structure, POA indicators, severity/risk concepts, E/M criteria, staff training/teaching, data collection/analysis, and conflict resolution

Benefits

A comprehensive federal employee benefits package is provided; eligibility depends on position type and status.