Medical Records Technician (Clinical Documentation Improvement Specialist- CDIS-Outpatient))

Summary

This position is located within the Health Information Management (HIM) section of the Health Administration Service at the Charlie Norwood VA Medical Center. Medical Records Technicians (Coder) serving as Clinical Documentation Improvement Specialists (CDIS - Outpatient) are highly skilled in classifying medical data from patient health records across both hospital and physician-based settings, including group practices, multi-specialty clinics, and specialty centers

Duties

Duties include but are not limited: Responsible for reviewing the overall quality and completeness of outpatient clinical documentation, ensuring all monitored, evaluated, assessed, and treated conditions are captured accurately and supported by clinical indicators. Conducts concurrent or retrospective reviews of health records to identify ambiguous, conflicting, incomplete, or nonspecific provider documentation. Ensures documentation accurately reflects the patient's true severity of illness (SOI), risk of mortality (ROM), resource utilization, and continuity of care. Performs retrospective reviews of outpatient encounters-prior to coding and billing-to improve provider documentation and support accurate reporting. Applies comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to validate proper code selection and high-quality healthcare data reporting. Collaborates with clinical staff through written, verbal, or electronic clarification requests (queries) to resolve documentation uncertainties. Reviews outpatient clinical documentation and delivers education to clinical staff regarding documentation requirements for all outpatient episodes of care. Prepares and conducts provider education sessions explaining documentation processes, coding impacts, workload implications, quality measures, reimbursement, and funding considerations. Prevents introduction of unsupported clinical indicators that do not align with the patient's condition for the current encounter and must not be added solely to increase reimbursement. Provides education to providers on the need for accurate and complete health record documentation, including proper selection of Evaluation & Management (E/M), CPT, and ICD-10 codes, ensuring documentation supports the highest level of specificity. Assists facility staff with understanding documentation requirements to ensure the patient care provided is fully and accurately reflected in the health record. Consults directly with professional clinical staff to clarify conflicting or ambiguous clinical data. Reports incorrect or insufficient documentation found in the electronic patient health record. Adheres to accepted coding practices, guidelines, and conventions when verifying appropriate diagnosis, procedure, ancillary, and E/M codes to promote ethical, accurate, and complete coding. Monitors regulatory and policy changes that affect coded data across all VA Medical Center (VAMC) services, ensuring timely compliance to maintain database accuracy and support cost-recovery programs. Reviews Veterans Equitable Resource Allocation (VERA) input to identify missed documentation opportunities and coordinates provider education with the VERA Coordinator. Ensures documentation supports codes based on VERA guidelines for diagnoses, procedures, and criteria used to classify patients according to condition severity and resource needs. Searches the patient health record thoroughly to locate supporting documentation for accurate code assignment, relying on detailed knowledge of record structure and content. Queries medical staff and other clinical caregivers as necessary to secure complete, clear, and accurate documentation. Uses multiple computer applications daily, including Outlook, Excel, Word, Access, electronic health record systems, and encoder/CDI software. Develops and conducts seminars, workshops, briefings, short courses, and conferences related to clinical documentation and training needs for clinical and Health Information Management (HIM) staff. Ensures an active intra-departmental training program for HIM staff, identifying and meeting training needs for professional, para-professional, and non-professional personnel. Provides orientation and training to newly assigned interns and residents and participates in hospital-wide in-service training programs. Facilitates improved quality, completeness, and accuracy of health record documentation through extensive interaction with physicians, caregivers, and coding staff, ensuring documentation fully supports services rendered. Collaborates with professional clinical staff and provides ongoing support and education on documentation-related issues. Assists in the development of guidelines to ensure data compatibility, consistency, and compliance across clinical, financial, and administrative documentation. Monitors and evaluates documentation practices to ensure all information is fully recorded, supported, and compliant with established standards. Works to enhance documentation quality to support accurate billing processes, reduce denials, prevent fraud and abuse, and ensure the medical center receives authorized reimbursement for resources utilized. Work Schedule:7:00 am -3:30pm Monday- Friday Functional Statement #:62487F Relocation/Recruitment Incentives: 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 (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.

Qualifications and evaluation

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. 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.

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: 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/.

How to apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 08/11/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/13020430. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

Required documents

To apply for this position, you must provide a complete Application Package which includes: Professional Certification Resume Transcript Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field. Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field. 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 (VA) License Other (1) Professional Certification Resume SF-50/ Notification of Personnel Action Transcript

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. 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.