Medical Records Technician CDIS (Outpatient and Inpatient)

Total Rewards of a Allied Health Professional

MRT CDISs must be able to perform all duties of a Medical Records Technician (MRT) (Coder-Outpatient and Inpatient). The MRT CDIS serves as a technical expert in health record content and documentation requirements.

The duties of the Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) in the Business Office include but not limited to:

• Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house.
• 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 inpatient episodes of care.
• Prepare and conduct 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 ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices guidelines and conventions 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. 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 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. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
• 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.

Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• 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.
• 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.

• 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

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: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).
• 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 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
  • (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. 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. (b) 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).

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.

• Master Level Certification: This is considered a higher-level health information management or coding certification and is limited to those 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 & are not acceptable for qualifications. Certification titles may change & 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 Informatic Administrator (RHIA) Certified Professional Coder (CPC) Certified Outpatient Cordera (COC) Certified Inpatient Coder (CIC).
• 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 & 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) & Certified Clinical Documentation Specialist (CCDS