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MEDICAL RECORDS TECHNICIAN (CDIS outpatient)

Department of Veterans Affairs
Veterans Health Administration
Veterans Health Administration
This job announcement has closed

Summary

This position is located in the Health Information Management (HIM) Section, under the Business Office, at the VA Medical Center, Atlanta, Ga.

Overview

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Reviewing applications
Open & closing dates
07/07/2025 to 07/18/2025
Salary
$64,625 to - $84,010 per year
Pay scale & grade
GS 9
Location
1 vacancy in the following location:
Atlanta, GA
1 vacancy
Remote job
No
Telework eligible
No
Travel Required
Not required
Relocation expenses reimbursed
No
Appointment type
Permanent
Work schedule
Full-time
Service
Competitive
Promotion potential
9
Supervisory status
No
Security clearance
Not Required
Drug test
No
Position sensitivity and risk
Non-sensitive (NS)/Low Risk
Announcement number
CBTB-12756017-25-RM
Control number
840189800

Duties

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  • CDI programs play an integral role in the hospital revenue cycle and quality assurance.
  • The risks associated with incomplete documentation can be high ranging from inaccurate treatment to inadequate treatment.
  • The Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating improved overall quality, education and completeness and accuracy of medical record documentation, as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations.
  • CDI is responsible for performing reviews of the health record documentation; collecting data, graphing and analyzing results; creating reports and communicating in writing and/or person to appropriate leadership and committees.
  • CDl Specialists can come from a varied background, Registered Nurses, Health Information Management professionals, and/or Compliance Officers; however, the positional classification has been determined nationally to fall into the Medical Record Technician series
Work Schedule: Monday - Friday 08:00 am to 04:30 pm
Financial Disclosure Report: Not required

Requirements

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Conditions of employment

  • You must be a U.S. Citizen to apply for this job
  • Designated and/or random drug testing may be required
  • Selective Service Registration is required for males born after 12/31/1959
  • You may be required to serve a probationary period
  • Subject to a background/security investigation
  • Must be proficient in written and spoken English
  • Selected applicants will be required to complete an online onboarding process

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.
  • Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
    • Mastery Level Certification through AHIMA or AAPC.
    • 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 Determinations:(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient/Inpatient);(b) Demonstrated Knowledge, Skills, and Abilities.
  • 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, 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.
References: VA Handbook 5005/122, Part II Appendix G57

The full performance level of this vacancy is GS-9

Physical Requirements: his position is sedentary with the occasional lifting 15 pounds or less.


Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Additional information

Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

This job opportunity announcement may be used to fill additional vacancies.

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, résumé, 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.

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