• Videos

  • Help



    This position is located in the Health Information Management section at the Durham VA Health Care System. The Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient) is responsible for reviewing the overall quality and completeness of clinical documentation. Outpatient clinical documentation improvement focuses on improving clinical staff documentation of outpatient encounters through retrospective review of outpatient encounters and extensive provider education.

    Learn more about this agency


    NOTE: These vacancies are advertised under job announcement numbers CBTA-11104294-21-CL and CBTA-11104295-21-CL. Current, permanent Federal employees should apply for consideration under CBTA-11104294-21-CL.

    As a Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient), you will serve as the liaison between health information management and clinical staff. Your duties will include, but are not limited to:

    • Perform all duties of a Medical Records Technician (Coder-Outpatient).
    • Apply comprehensive knowledge of medical terminology, anatomy and 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.
    • Adhere 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.
    • Review clinical documentation and provide 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.
    • Provide 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 ensure documentation supports the codes selected to the highest degree of specificity.
    • Review VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator. Ensure 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.
    • Monitor ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the medical center.
    • Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided; provide technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensure provider documentation is complete and supports the diagnoses and procedures coded. Consult with the professional staff for clarification of conflicting or ambiguous clinical data. Report incorrect documentation or codes in the electronic patient health record.
    • Search the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Query the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
    • Develop and conduct 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.
    • Facilitate 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.
    • Ensure 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. Identify trends and/or opportunities to improve clinical documentation.
    • Compile, review, abstract, analyze and interpret medical data incidental to a variety of patient care and treatment activities. Review the health record and discuss the case with the clinical staff. Perform chart reviews for specific patient populations to facilitate appropriate clinical documentation and ensure the level of services and acuity of care are accurately reflected in the health record.
    • Maintain statistical database(s) 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.

    Work Schedule: First Shift, 8:00 am - 4:30 pm
    Financial Disclosure Report: Not required
    Telework: May be approved for highly qualified applicants upon completion of facility telework criteria

    Travel Required

    Not required

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/600354600. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.