Medical Records Technician (Clinical Documentation Improvement Specialist- CDIS-Outpatient))

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 experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, and medical coding. The structure and format of a health records .One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); 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. 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, (4) 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 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). Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement Certification. Employees at this level must have a mastery level certification or a clinical documentation improvement certification : Apprentice/Associate Level Certification through AHIMA or AAPC. 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: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates :Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient ) GS-09 Experience One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient). 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 Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. (b) Certification. Employees at this level must have either a mastery level certification or a Clinical Documentation Improvement Certification Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Knowledge of coding and documentation concepts, guidelines, and clinical terminology. Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order 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 ICD, CPT, and HCPCS) Knowledge of 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. 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 Preferred Experience: 1-2 years experience as GS-0675-08 MRT Coder - Outpatient at Veterans Health Administration (VHA) facility. Demonstrated full-performance level VHA outpatient coding experience, including proficiency in VHA coding policies, outpatient coding guidelines, and accurate documentation practices Reference: For more information on this qualification standard, please visit VA.gov | Veterans Affairs . The full performance level of this vacancy is GS- 9. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. This position is located within the Health Information Management (HIM) section of the Health Administration Service at the Charlie Norwood VA Medical Center. Medical Records Technicians (Coder) serving as Clinical Documentation Improvement Specialists (CDIS - Outpatient) are highly skilled in classifying medical data from patient health records across both hospital and physician-based settings, including group practices, multi-specialty clinics, and specialty centers

• Duties include but are not limited: Responsible for reviewing the overall quality and completeness of outpatient clinical documentation, ensuring all monitored, evaluated, assessed, and treated conditions are captured accurately and supported by clinical indicators. Conducts concurrent or retrospective reviews of health records to identify ambiguous, conflicting, incomplete, or nonspecific provider documentation. Ensures documentation accurately reflects the patient's true severity of illness (SOI), risk of mortality (ROM), resource utilization, and continuity of care. Performs retrospective reviews of outpatient encounters-prior to coding and billing-to improve provider documentation and support accurate reporting. Applies comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to validate proper code selection and high-quality healthcare data reporting. Collaborates with clinical staff through written, verbal, or electronic clarification requests (queries) to resolve documentation uncertainties. Reviews outpatient clinical documentation and delivers education to clinical staff regarding documentation requirements for all outpatient episodes of care. Prepares and conducts provider education sessions explaining documentation processes, coding impacts, workload implications, quality measures, reimbursement, and funding considerations. Prevents introduction of unsupported clinical indicators that do not align with the patient's condition for the current encounter and must not be added solely to increase reimbursement. Provides education to providers on the need for accurate and complete health record documentation, including proper selection of Evaluation & Management (E/M), CPT, and ICD-10 codes, ensuring documentation supports the highest level of specificity. Assists facility staff with understanding documentation requirements to ensure the patient care provided is fully and accurately reflected in the health record. Consults directly with professional clinical staff to clarify conflicting or ambiguous clinical data. Reports incorrect or insufficient documentation found in the electronic patient health record. Adheres to accepted coding practices, guidelines, and conventions when verifying appropriate diagnosis, procedure, ancillary, and E/M codes to promote ethical, accurate, and complete coding. Monitors regulatory and policy changes that affect coded data across all VA Medical Center (VAMC) services, ensuring timely compliance to maintain database accuracy and support cost-recovery programs. Reviews Veterans Equitable Resource Allocation (VERA) input to identify missed documentation opportunities and coordinates provider education with the VERA Coordinator. Ensures documentation supports codes based on VERA guidelines for diagnoses, procedures, and criteria used to classify patients according to condition severity and resource needs. Searches the patient health record thoroughly to locate supporting documentation for accurate code assignment, relying on detailed knowledge of record structure and content. Queries medical staff and other clinical caregivers as necessary to secure complete, clear, and accurate documentation. Uses multiple computer applications daily, including Outlook, Excel, Word, Access, electronic health record systems, and encoder/CDI software. Develops and conducts seminars, workshops, briefings, short courses, and conferences related to clinical documentation and training needs for clinical and Health Information Management (HIM) staff. Ensures an active intra-departmental training program for HIM staff, identifying and meeting training needs for professional, para-professional, and non-professional personnel. Provides orientation and training to newly assigned interns and residents and participates in hospital-wide in-service training programs. Facilitates improved quality, completeness, and accuracy of health record documentation through extensive interaction with physicians, caregivers, and coding staff, ensuring documentation fully supports services rendered. Collaborates with professional clinical staff and provides ongoing support and education on documentation-related issues. Assists in the development of guidelines to ensure data compatibility, consistency, and compliance across clinical, financial, and administrative documentation. Monitors and evaluates documentation practices to ensure all information is fully recorded, supported, and compliant with established standards. Works to enhance documentation quality to support accurate billing processes, reduce denials, prevent fraud and abuse, and ensure the medical center receives authorized reimbursement for resources utilized. Work Schedule:7:00 am -3:30pm Monday- Friday Functional Statement #:62487F Relocation/Recruitment Incentives: Not Authorized