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

Total Rewards of a Allied Health Professional

Outpatient CDISs serve as the liaison between health information management and clinical staff. They are responsible for facilitating improved overall quality education completeness and accuracy of health record documentation through extensive interaction with clinical coding and other associated staff to ensure clinical documentation supports services rendered to patients appropriate workload and resource allocations. They review documentation and facilitate modifications to the health record to ensure accurate complexity of care and utilization of resources. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity accurately address all acute and chronic conditions and reflect the true health status of patients. They recommend changes and/or updates to medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous conflicting or incomplete documentation.

Responsible for reviewing the overall quality and completeness of clinical documentation. Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective ideally prior to coding and billing review of outpatient encounters and extensive provider education.

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.

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 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. 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.



Work Schedule: Monday - Friday; 8:00am - 4:45pm
Recruitment Incentive (Sign-on Bonus): Not Authorized
Permanent Change of Station (Relocation Assistance): Not Authorized
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 $144000 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: Ad-hoc. Available
Virtual: This is not a virtual position.
Functional Statement #: 56037-F
Permanent Change of Station (PCS): Not Authorized

• 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 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.

• 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.

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

• An Associate Degree or higher in a healthcare related field and three (3) years of experience in Clinical Documentation Improvement.
• Mastery level certification through AHIMA or AAPC and two (2) years of experience in Clinical Documentation Improvement.
• Clinical experience such as RN MD or DO and one year of experience in Clinical Documentation Improvement.
• Knowledge of anatomy and physiology pathophysiology and pharmacology to interpret and analyze all information in a patients health record including laboratory and other test result.
• Knowledge inpatient acute care and/or outpatient surgical and ancillary medical coding and introduction to health records.
• Knowledge and use of Clinical Documentation Integrity Artificial Intelligence (AI) software platforms.
• Ability to establish and maintain strong verbal and written communication with providers.
• Experience working with CDI metrics developing excel reports designing excel graphics and presenting this date to various committees.