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

Summary

This position is located within the Department of Veterans Affairs(VA), Veterans Health Administration(VHA), James A. Haley VA hospital. Clinical Documentation Integrity Specialists(CDIS) must be able to perform all duties of MRT(Coder-outpatient and Inpatient). CDIS's serve as the liaison between Health Information Management and clinical staff.

Duties

Clinical Documentation Improvement Specialists (CDIS) review documentation in the medical record and information in an inpatient Patient Treatment File (PTF) and in outpatient encounters and facilitate modifications to the health record to identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity and accurately address all acute and chronic conditions. Other Duties and Functions include but are not limited to: Serve as a 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 the review of query reports. Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of inpatient records with an emphasis on improving documentation while the patient is still in-house while Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective review of outpatient encounters. Provides education to the providers on documentation improvement in the health record to include the impact of documentation on coding, quality measures and reimbursement. Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinates provider documentation education with the VERA coordinator. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the facility. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Queries providers for clarification of conflicting or ambiguous documentation. Identifies trends and opportunities to improve documentation. Uses a variety of computer applications in daily activities and duties, such as Outlook, Excel, Word, and Power Point and is competent in the use of the health record applications VistA and CPRS as well as the Solventum encoder product suite and WebVIRR suite of products for PTF completion, Encounter Completion and Compliance E-mail Tracking. Work Schedule: Monday- Friday: 7:30a.m to 4:00 p.m. Telework: Ad-hoc Virtual: This is not a virtual position. Functional Statement #: 70210F

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. 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

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: 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 10/26/2026 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/13071005. 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: Long-form resume/Curriculum vitae (CV) RESUME REMINDER- Please ensure EACH work history includes ALL of the following information: Resume - To determine your eligibility, please ensure resume includes the below: Job title Grade Level (for Federal positions) Duties (be as detailed as possible and ensure they demonstrate how you meet the specialized experience and/or Knowledge, Skills and Abilities required for the position Month & year start/end dates (e.g. June 2007 to April 2008) Full-time or part-time status Include 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 Long-form resume/Curriculum vitae (CV) Professional Certification 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.