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

Wallops Island, Virginia
Aug 10, 2022
Aug 17, 2022
Full Time

***** This is an open continuous vacancy announcement. This announcement is intended as a mechanism of providing consideration for the greatest number of potential candidates. Applicants will first be referred 10 calendar days after the opening date and periodically throughout the announcement period. Final application disposition will be completed once all positions have been filled or the announcement reaches the end of the open period stated in the announcement. ******
This job opportunity announcement (JOA) will be used to fill one (1) Medical Records Technician (Clinical Documentation Improvement Specialist(CDIS-Outpatient and Inpatient)), GS-0675-09 vacancy at the Murfreesboro, TN Veteran Affairs Medical Center (VAMC), with Business Office Service.

This position is located in the Health Information Management (HIM) section in the Business Office at the (TVHS). MRTs (CDIS) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. To perform this task, they must possess expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (CDIS) also provide education related to coding and documentation.
  • Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS0679-09. CDISs must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient).
  • Serve as the liaison between health information management and clinical staff.
  • Responsible for facilitating improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated.
  • Review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
  • Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients.
  • Develop and/or update medical center policy pertaining to clinical documentation improvement.
  • Are technical expert in health record content and documentation requirements.
  • Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
  • Review appropriateness of and responses to queries through review of query reports.
  • Review health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership.
  • Obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.
  • Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements.
  • Monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education.
  • Responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met.
  • Provide training, educating clinical staff about current documentation standards and improvement techniques.
  • Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures.
Work Schedule: Monday - Friday 7:30 a.m. - 4:00 p.m.
Telework: Available for highly qualified applicants.
Telework. A flexible work arrangement under which an employee performs the duties and responsibilities of such employee's position, and other authorized activities, from an approved worksite other than the location from which the employee would otherwise work.
Virtual Work. Work performed on a full-time basis using VA-leased space or at a VA facility other than the facility that hired the employee.
Remote Work. Work performed on full-time basis anywhere other than a VA facility or using VA-leased space.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
inancial Disclosure Report: Not required


Conditions of Employment

  • 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.
  • You may be required to serve a probationary period.
  • Subject to background/security investigation.
  • Selected applicants will be required to complete an online onboarding process.
  • 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).
  • Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.


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. Must be proficient in spoken and written English.
  • Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
  • Experience and Education
    • (1) Experience. One 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,
    • (2) 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,
    • (3) 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,
    • (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
  • Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
    • (1)Apprentice/Associate Level Certification through AHIMA or AAPC.
    • (2)Mastery Level Certification through AHIMA or AAPC.
    • (3)Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • a. Journey Level. The full performance level for the MRT (Coder) assignment is GS-8.
  • b. Creditable Experience. Experience is only creditable if it is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities (KSAs) associated with current practice and must be paid or non-paid employment equivalent to a MRT (Coder).
  • c. Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference or through other independent means.
  • d. Mastery Level Certification. This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P),Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder(COC), Certified Inpatient Coder (CIC).
  • e. Clinical Documentation Improvement Certification. This is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist(CCDS).
In addition to the basic requirements, the below qualification requirements must be met at the grade in which you are applying.

Grade Determinations: GS-9
(a.) Experience and/or Education: To Qualify for the GS-09 CDIS, you must have one of the following education and or experience.
(1.) One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient); OR,
(2.) 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,
(3.) Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement; OR,
(4.) Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

(b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. See definitions d. and e. above.

(c) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  • i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
  • ii. 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.
  • iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
  • iv. Ability to establish and maintain strong verbal and written communication with providers.
  • v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
  • vi. 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.
  • vii. 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.
  • viii. 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.
References: VA Handbook 5005/122, Part II, Appendix G57

Physical Requirements: The majority of work is performed in an office setting, primarily while seated. The position requires some standing, ambulation, bending and carrying of items such as training manuals. In addition, there can be increased stress due to the intensity of a patient/customer complaint or concern.


IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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: .

Additional information

Receiving Service Credit or 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.

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.

To ensure compliance with an applicable preliminary nationwide injunction, which may be supplemented, modified, or vacated, depending on the course of ongoing litigation, the Federal Government will take no action to implement or enforce the COVID-19 vaccination requirement pursuant to Executive Order 14043 on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees. Therefore, to the extent a VA job announcement includes language requiring applicants to be fully vaccinated against COVID-19 pursuant to Executive Order 14043, that requirement does not currently apply to this Job Announcement. VA may request information regarding your vaccination status, if selected, for the purposes of implementing other workplace safety protocols, such as masking, physical distancing, testing, travel, and quarantine.

If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application .