Supervisory Clinical Documentation Improvement (CDI) Coder

Quick Facts

• Role: Supervisory Clinical Documentation Improvement (CDI) Coder (MRT Coder)

• Focus: Inpatient and outpatient documentation integrity and coding education

• Schedule: Monday–Friday, 8:00–4:30 CST

Description

This position supervises clinical documentation improvement and coding quality by serving as a liaison between Health Information Management (HIM) and clinical staff. The role reviews documentation quality and completeness, educates providers and staff on proper documentation practices (including E/M, CPT, and ICD-10 specificity), and ensures documentation supports services rendered and drives accurate coding, workload capture, and quality measures. The supervisor also analyzes documentation and coding trends using ongoing reviews and statistical reporting to identify improvement opportunities.

Responsibilities

• Review overall clinical documentation quality and completeness for inpatient and outpatient episodes (admissions/discharges, observation, ED/urgent care, and clinic visits)

• Educate clinical staff and providers on documentation processes and the impact on coding, workload, quality measures, reimbursement, and funding

• Teach documentation needs for accurate E/M code selection and appropriate CPT and ICD-10 diagnosis/procedure specificity

• Conduct seminars, workshops, short courses, and briefings for clinical and HIM staff on documentation improvement

• Ensure accurate documentation used to measure/report physician and medical center outcomes; identify trends and improvement opportunities

• Conduct daily reviews of new admissions for documentation improvement opportunities

• Maintain and analyze statistical databases; produce regular reports to medical staff and management

• Collect, review, abstract, analyze, and interpret medical data related to patient care and treatment activities

Requirements

• U.S. citizenship; selective service registration for eligible males

• Proficient in written and spoken English; subject to background/security investigation

• Complete online onboarding and pre-employment requirements; pass pre-employment physical; comply with required seasonal influenza vaccination

• Meet basic education/experience requirements in medical terminology, anatomy/physiology/pathophysiology, and medical coding/health record structure

• Hold required certifications for MRT (Coder) in the GS-0675 series (e.g., AHIMA/AAPC mastery or CDI certification)

• For GS-10: demonstrate one year of specialized experience equivalent to GS-9 in CDIS liaison and documentation improvement work

• Demonstrate KSAs: supervisory duties (evaluation, leave approval, resolving issues, work planning/coordinating), advanced coding classification knowledge (ICD/CPT/HCPCS), inpatient severity/POA/MS-DRG knowledge, training/teaching capability, leadership/conflict resolution, and data collection/analysis/reporting

• Preferred: minimum 3 years of inpatient CDIS/coding/auditing experience

Benefits

• Competitive salary with regular salary increases

• Paid Time Off: 37–50 days annual paid time off per year (annual leave, sick leave, and federal holidays)

• Potential credit toward annual leave accrual for selected applicants

• Up to 12 weeks paid parental leave after 12 months of employment

• Child care subsidy eligibility after 60 days for full-time employees under specified income limits

• Retirement: federal pension and federal 401(k) with up to 5% contributions

• Insurance: federal health/vision/dental/term life/long-term care

• Telework authorized; position is not virtual