The major duties of a Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient) include, but are not limited to, the following

• Reviews clinical documentation for completeness, accuracy, clarity, and specificity through concurrent and retrospective inpatient record review.
• Ensures documentation supports all monitored, evaluated, assessed, and treated conditions, accurately reflecting SOI, ROM, and resource use.
• Performs concurrent CDI reviews to improve documentation while the patient is still admitted.
• Applies knowledge of anatomy, physiology, disease processes, treatments, diagnostics, medications, and procedures to support accurate documentation and code selection.
• Collaborates with clinical staff using written, verbal, or electronic queries to clarify ambiguous or incomplete documentation.
• Provides education to providers on accurate, complete inpatient documentation and its impact on coding, quality, reimbursement, and funding.
• Reports incorrect or insufficient documentation in the electronic health record.
• Follows inpatient coding guidelines to verify appropriate diagnosis and procedure code selection and maintains compliance with regulatory updates.
• Uses EHR applications, encoders, CDI software, and tools such as Outlook, Excel, Word, and Access.
• Develops and delivers documentation training sessions, workshops, and briefings for clinical and HIM staff.
• Assists in developing guidelines for data consistency, compatibility, and compliance to support clinical, administrative, and financial accuracy.
• Provides expertise on documentation requirements, privacy, confidentiality, informed consent, liability issues, and reporting mandates.

Work Schedule: Monday - Friday 8:00am - 4:30pm
Remote: This position is designated as remote. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center (NOTE: This does not include CBOCs).
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the 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

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: Proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

And;
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 associate's 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,
• 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.
  • (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.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determination: In addition to the Basic Requirements above, candidates must also meet any additional requirements to include KSAs based on grade assignment below.

GS-09 Experience. One year of creditable experience equivalent to the GS-8 grade level of an MRT (Coder-Inpatient); OR,

An associate's 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; OR,

Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement

AND;.

Demonstrated KSAs: In addition to the experience above, the employee must demonstrate all of the following KSAs:

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's 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, including current clinical classification systems such as ICD-CM and ICD-PCS. Candidate must possess a 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, and complexity of care; and
• 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.

Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

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-9. The actual grade at which an applicant may be selected for this vacancy is GS-9

Physical Requirements: See VA Directive and Handbook 5019.