Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. This vacancy is opened to all U. S. Citizens. (Non-citizens may be appointed when it is not possible to recruit qualified citizens). Tuscaloosa VAMC employees will receive first consideration.

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Major duties include but are not limited to:

• Reviews inpatient and outpatient clinical documentation to ensure accuracy, completeness, and support of correct code assignment, severity of illness, and resource utilization.- Conducts concurrent and retrospective documentation reviews; identifies opportunities for clarification and improvement.
• Serves as a liaison between HIM and clinical providers, facilitating communication to improve documentation quality and compliance
• Queries clinicians to clarify ambiguous, incomplete, or conflicting documentation; evaluates responses for accuracy and compliance with coding and documentation standards.
• Provides focused education to providers on documentation requirements, E/M coding, CPT/ICD-10 specificity, and the impact of documentation on workload, quality measures, VERA, and reimbursement.
• Assists in developing, updating, and implementing policies and guidelines related to clinical documentation improvement.
• Reviews admissions, DRGs, treatment plans, lab results, and diagnostic data to verify documentation reflects patient acuity and clinical conditions.
• Participates in interdisciplinary rounds to offer guidance on documentation, coding rules, DRG methodology, and reimbursement considerations.
• Monitors trends or changes in industry standards, regulations, and coding guidance; identifies training needs and coordinates education with HIMS leadership and other stakeholders.
• Collaborates with Provider Auditor and HIMS leadership to ensure accurate provider documentation and compliance with regulatory and accreditation requirements.
• Maintains documentation review statistics, prepares summary reports, and analyzes data to identify trends, measure program effectiveness, and support leadership decision-making.
• Ensures provider documentation aligns with national guidelines, VA policy, UHDDS definitions, and ethical coding practices.
• Supports internal audits, compliance reviews, and process-improvement initiatives related to documentation, coding accuracy, and billing integrity.
• Provides technical expertise and guidance on health record documentation issues, including patient confidentiality, informed consent documentation, legal requirements, and record content standards.
• Contributes to staff training, orientation of new clinical providers, and intra-departmental education programs to strengthen documentation accuracy and quality.
• Performs other duties as assigned.

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.
• 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.

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. 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: (a) 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. (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) 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.
• Grandfathering Provision. All persons employed in VHA as a MRT (Coder) on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series, and grade held, including positive education and certification that are part of the basic requirements of the occupation.
• Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
• English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).

• One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and 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; NOTE: See paragraph 2g for a detailed definition of mastery level certification. OR,
• Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.

• Knowledge of coding and documentation concepts, guidelines, and clinical 25 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, to include current clinical classification systems such as ICDCM and PCS, CPT, and HCPCS. They must also possess 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, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients.
• 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.

How you will be evaluated

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

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.

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position. You will be assessed on the following Competencies for this position:

• Attention to Detail
• Customer Service
• Decision Making
• Flexibility
• Integrity/Honesty
• Interpersonal Skills
• Learning
• Reading Comprehension
• Self-Management
• Stress Tolerance
• Teamwork