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

This position is located within the Grand Junction VA Healthcare System and must be filled within the VISN 19 catchment area. The employee must reside within 50 miles of one of the VISN 19 facilities: Grand Junction Colorado; Denver Colorado; Sheridan Wyoming; Cheyenne Wyoming; Oklahoma City Oklahoma; Muskogee Oklahoma; Salt Lake City Utah; or Fort Harrison Montana.

• Responsible for reviewing the overall quality and completeness of clinical documentation.
• 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.
• Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges observation emergency department/urgent care and clinic visits.
• Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding workload quality measures reimbursement and funding.
• Provides education to providers on the need for accurate and complete documentation in the health record appropriate code selection of Evaluation and Management (E/M) Current Procedural Terminology (CPT) and ICD-10 diagnosis codes and ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices guidelines and conventions when choosing the most appropriate diagnosis operation procedure ancillary or evaluation and management (E/M) code to ensure ethical accurate and complete coding.
• Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• 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.
• 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 computer 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.
• Develops and conducts seminars workshops short courses informational briefings and conferences concerned with health record documentation educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
• Collaboratively works with the professional clinical staff and provides support and education on documentation issues.
• 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.
• Compiles reviews abstracts analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
• Participates in clinical rounds and may where appropriate offer information on documentation coding rules and reimbursement issues.
• Maintains statistical databases to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.

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.
• 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 ( Effective May 7 2025 drivers licenses or state-issued dentification 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.

• 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.

Qualifications

*** This is an OPEN CONTINUOUS ANNOUNCEMENT and will remain open until May 4th 2026. The initial cutoff date for referral of eligible applications will be December 4th 2025. Eligible applications received after that date will be referred at regular intervals or as additional vacancies occur on an as needed basis until positions are filled. ***

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.

Experience and Education 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

Education. An associates 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:(a) 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.

OR

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:(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.

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.

GRADE REQUIREMENTS 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 associates 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.

GS 9-Certification Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

GS-9 Knowledge Skills and Abilities (KSAs)-In addition to the experience above you must demonstrate the following KSAs.

• Knowledge of coding and documentation concepts guidelines and clinical terminology.
• Knowledge of anatomy and physiology pathophysiology and pharmacology in order to interpret and analyze all information in a patients 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 ICD 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.
• 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.