Medical Records Technician (Clinical Documentation Improvement Specialist Cdis – Inpatient)

Summary

Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS – Inpatient)) is located in the Health Information Management (HIM) section of the Health Administration Service at the VA Maryland Health Care System. Medical Records Technicians are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multispecialty clinics, and specialty centers.

Duties

• Total Rewards of a Allied Health Professional Duties to include but not limited to: 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 clinical documentation supports proper code selection and reporting of high quality healthcare data.
• Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.
• 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), CPT and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
• Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
• Reports incorrect documentation in the electronic patient health record.
• Adheres to accepted coding practices, guidelines and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or E/M code to ensure ethical, accurate, and complete coding.
• 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 electronic health record applications as well as the encoder and/or CDI 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 active intra-departmental training program is in place for the HIM staff.
• Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital.
• Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.
• Work Schedule: 7:30am-4:00pm, Monday-Friday 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).
• 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.
• Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 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: Not available
• Virtual: This is a virtual position.
• Functional Statement #: 260154F

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
• 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.

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/.

Required Documents

• To apply for this position, you must provide a complete Application Package which includes:
• Full resume/CV may be uploaded without page limitation Clinical Documentation Improvement Certification or Mastery Level Certification Resume Special Note for
• Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume
• This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.
• Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.
• 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
• DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) License
• Full resume/CV may be uploaded without page limitation Clinical Documentation Improvement Certification or Mastery Level Certification Other (3) Performance Appraisal Professional Certification Resume Separation Notice (RIF)
• SF-15 SF-50/ Notification of Personnel Action Transcript