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Summary The Inpatient CDIS serves as the liaison between Health Information Management and clinical staff. They are 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 service rendered to patients, appropriate workload is captured, and resources are properly allocated. Responsibilities Major duties for the Medical Records Technician (CDIS - Inpatient) include (but are not limited to) : Responsible for reviewing the overall quality and completeness of clinical documentation. Health records are reviewed either concurrently or retrospectively for ambiguous, conflicting, incomplete, or nonspecific provider documentation. The goal of these reviews is to-ensure that all conditions monitored, evaluated, assessed and treated, or that impact the patient's care are documented as completely and precisely as possible and supported by the clinical indicators present in the health record. This helps to capture the patient's true risk of mortality (ROM)/severity of illness (SOI), supports resource consumption, and enhances continuity of care. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house. Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure clinical documentation supports proper code selection and reporting of high quality healthcare data. Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries. Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care. 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. Documentation must support the care provided as well the health status of the patient. Any clinical indicators not supported by the patient's condition for the current episode of care or encounter must not be introduced solely to increase financial reimbursement. Provides education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation in the electronic patient health record. Adheres to accepted coding practices, guidelines, and conventions when verifying the most appropriate diagnosis, operation, or procedure code to ensure ethical, accurate, and complete coding. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Reviews Veterans Equitable Resource Allocation (VERA) input on missed opportunities in provider documentation identified by the VERA Coordinator and coordinates provider documentation education with the VERA Coordinator. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the VERA program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation. Uses a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of electronic health record applications as well as the encoder and/or CDI product suite. Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. Ensures active intra-departmental training program is in place for the HIM staff. Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents and participates in in-service programs conducted throughout the hospital. Work Schedule: Monday - Friday 6:00am - 6:00pm Compressed/Flexible: Available Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 30924-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements 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. You may be required to serve a trial period. 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. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). 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. English Language Proficiency: MRTs (CDIS- Inpatient) must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), 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. 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: This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, 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). Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists. 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 GS-9: 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 Preferred Experience: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. 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). Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist (CCDS). Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Physical Requirements: The work is primarily sedentary. There is walking, bending and reaching required such as for filing or locating material, and carrying items such as reports, documents, and supplies. Entering data and word processing on a personal computer may result in physical problems from the effects of repetitive motion and eyestrain. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. 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. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. 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. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.