Medical Records Technician (Clinical Documentation Improvement Specialist (Out/Inpatient))

The MRT (Coder) in the Health Information Management section analyzes patient health records, abstracts clinical information, and assigns accurate ICD, CPT, and HCPCS codes for diagnoses and procedures. The role requires knowledge of medical coding standards and documentation requirements and may include educating staff on proper coding and documentation practices.

The Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS) is located within the Health Information Management Section (HIMS) of the Business Operations Service (BOS) at the Kansas City VA Medical Center (KCVAMC).Incumbent provides quantitative and qualitative review and analysis of medical records and encounter forms of both inpatient and outpatient encounters to ensure all diagnoses and conditions for which care is being rendered are documented by the provider in the proper sequence, and procedures have been documented and/or evaluation and management services.

Major Duties include, but are not limited to:

• Responsible for reviewing the overall quality and completeness of clinical documentation
• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures
• Reviews clinical documentation and provides 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
• Monitors ever-changing regulatory and policy requirements affecting coded information
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements

Work Schedule: Monday-Friday; 7:30AM-4PMRetention Incentive: Maybe authorized for highly qualified candidates.Permanent Change of Station (Relocation Assistance): Not AuthorizedPay: 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 offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)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 VAInsurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Telework: Available
Virtual: This is not a virtual position.
Functional Statement #: 000000
Permanent Change of Station (PCS): Not Authorized
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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:
  • Six months of creditable experience that indicates knowledge of medical 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; OR
  • 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).

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).

Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. Do you possess one of the following required certifications? (Proof of certification must be provided at the time of application):

• Mastery Level Certification through AHIMA or AAPC. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC); OR
• Clinical Documentation Improvement Certification through AHIMA or ACDIS. Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.

GS-9 Experience Requirement: In addition to the basic requirements, you must possess the following:

• One year of creditable experience equivalent to the journey grade level (GS-8) 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; 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.

ANDKnowledge, Skills, and Abilities: For the Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient & Inpatient)), GS-9, in addition to the basic requirements, certificate requirement, and grade requirements; the candidates must be able to demonstrate the following knowledge, skills, and abilities:

• 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 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.

Preferred Experience: 2-3 years of concurrent or retrospective CDI experience in an inpatient/outpatient acute care facility.Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.The full performance level of this vacancy is 9.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

• 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 identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Must pass pre-employment physical evaluation/examination.
• 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.