Medical Records Technician (CDIS- Outpatient/Inpatient)

Summary

This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System VA Medical Center. The Medical Records Technician (CDIS- Outpatient/Inpatient) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

Duties

Major duties for the position include (but are not limited to): Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include current versions of the international Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Uses a variety of window-based applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (Vista and CPRS) as well as the encoder product suite. Ensures current versions of all software applications are loaded and functional after any updates or changes. Collaboratively works with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. As a technical expert in health record documentation matters, provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc. Analyzes situations or processes and recommends improvements or changes in documentation as deemed necessary. May assist in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation. Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Total Rewards of a Allied Health Professional Work Schedule: Work Schedule: Monday - Friday, 7:00 am - 3:30 pm, (Subject to change based on the needs of the facility.) Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Available Virtual: This is not a virtual position. Functional Statement #:00559F Permanent Change of Station (PCS): 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 evaluation. 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

**continuation of qualifiactions Preferred Qualifications Current CDI certification (CCDS, CCDS-O, CDIP, CDEO, or CDEI); none preferred over another. Experience with both concurrent inpatient review and retrospective outpatient review. Proficiency in ICD coding, plus CPT and HCPCS for outpatient encounters. Skill developing and reconciling provider queries, and knowledge of MS-DRG/APR-DRG, ROM/SOI concepts. Experience delivering provider documentation education. Strong collaboration and communication skills across clinical and coding teams. 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. The actual grade at which an applicant may be selected for this vacancy is GS-09. 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/. IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, pulling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment. Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated. However, the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations.

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 10/01/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/13064971. 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

Selections from this announcement will be made without regard to Veterans' preference in accordance with OCHCO Bulletin dated 9/25/2025. To apply for this position, you must provide a complete Application Package which includes: Resume Resume Requirement: Your resume must include the following information: Job title, description of duties, beginning and ending date (month/year) of employment, and average hours worked per week. 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) C/V Resume Mastery/Clinical Certification obtained through AHIMA , AAPC or ACDIS. PCS Orders Performance Appraisal Professional Certification Resume SF-15 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.