Medical Records Technician (Clinical Documentation Improvement Specialist) - Inpatient/Outpatient

The Medical Records Technician (Clinical Documentation Improvement Specialist) • Inpatient/Outpatient, GS-09, serves within the Health Information Management Service (HIMS) and is responsible for improving the overall quality, accuracy, completeness, and timeliness of clinical documentation in the health record. The Medical Records Technician (Clinical Documentation Improvement Specialist) • Inpatient/Outpatient collaborates with providers, nurses, coders, and other healthcare professionals to ensure documentation accurately reflects patient severity of illness, quality of care, resource utilization, and regulatory requirements. This position reviews medical records, identifies documentation deficiencies, provides education and guidance to clinical staff, and promotes compliance with coding, documentation, and reimbursement standards. The position directly supports patient care initiatives, performance improvement efforts, coding accuracy, data integrity, and organizational goals through effective clinical documentation improvement practices. Major Duties Reviews inpatient and outpatient medical records to identify opportunities for clinical documentation improvement. Collaborates with physicians, nurses, coders, and other healthcare staff to clarify and improve documentation accuracy. Analyzes health record documentation to ensure completeness, specificity, and compliance with regulatory requirements. Conducts concurrent and retrospective reviews of patient records to support accurate code assignment and reimbursement. Provides education and training regarding documentation standards, coding guidelines, and clinical documentation improvement initiatives. Monitors changes in coding regulations, documentation requirements, and industry standards and communicates impacts to stakeholders. Assists with policy development and process improvement activities related to documentation integrity and compliance. Evaluates documentation to support accurate assignment of diagnoses, procedures, severity of illness, risk of mortality, and quality measures. Performs clinical documentation audits, data analysis, and reporting to identify trends and opportunities for improvement. Participates in multidisciplinary rounds and serves as a clinical documentation resource for healthcare teams. Maintains documentation improvement databases and prepares reports for leadership and program oversight. Ensures compliance with VA policies, coding guidelines, privacy requirements, and health information management standards. Work Schedule: 8:00am • 4:30pm; Monday • Friday Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 40410F Relocation/Recruitment Incentives: Not Authorized THIS IS NOT A VIRTUAL POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION 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. Basic Requirements: United States Citizenship. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience and Education Experience. One (1) 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 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 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 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). Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. 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. Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-9 Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient); OR, An associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement; NOTE: See paragraph 2g above for a detailed definition of mastery level certification. OR, Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. NOTE: See paragraph 2g and 2h for a detailed definition of mastery level certification and clinical documentation improvement certification. Knowledge, Skills and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology. Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record, including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. Ability to establish and maintain strong verbal and written communication with providers. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators. Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients. Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.The full performance level of this vacancy is GS-09. Physical Requirements: No additional physical requirements. You must be a U.S. Citizen to apply for this job. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). 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. Must pass pre-employment physical examination. 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. 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: http://ope.ed.gov/accreditation/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.