Clarification from the agency

Open to current permanent Department of Veteran Affairs employees and other federal employees. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

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Duties

• Reviews overall quality and completeness of clinical documentation.
• Applies comprehensive knowledge of medical terminology, anatomy, and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures as well as principles and practices of health services and the organizational structure to ensure proper code selection.
• 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.
• Adheres to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding.
• Monitors changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Expertly searches the patient health record to find documentation justifying code assignment.
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, and educational and functional training requirements.

Work Schedule: Full-Time, 0800-1630 (subject to change)
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 off 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 $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 Authorized
Remote: Available - This position is remote work ELIGIBLE and is currently exempted from return to office requirements. Remote exempted position are reviewed annually and do not imply permanent remote work status.
Virtual: This is not a virtual position.
Functional Statement #: 0000000
Permanent Change of Station (PCS): Not Authorized

Conditions of employment

• 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 dentification 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 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.
• 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 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,
    • 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:
    • Six months of creditable experience that indicates knowledge of medical 4 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.
    • 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.

Grade Determination
GS 9 Medical Records Technician (Clinical Documentation Improvement Specialist - Inpatient)
Experience: One year of creditable experience equivalent to the journey grade level of a 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.

Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.
Assignment: For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Inpatient CDISs must be able to perform all duties of a MRT (Coder-Inpatient). CDISs serve as the liaison between health information management and clinical staff. They are 22 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 is captured, and resources are properly allocated. They review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, 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. They recommend changes and/or update 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. They review appropriateness of and responses to queries through review of query reports. They perform reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate groups and leadership. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. They monitor trends in the industry and/or changes in regulations that could or should impact coding and documentation practices and identify who may require education. They are responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met. They provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. They apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses, and complete significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

Area of Consideration - Eligible applications will be reviewed in the following order:

1. Current permanent VA employees of the facility
2. All other VA employees
3. Other federal employees

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.