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Summary The 2-page Resume requirement does not apply to this occupational series. For more information, refer to Required Documents below. Clinical Documentation Improvement Specialists (CDIS) must be able to perform all duties of a MRT(Coder-Outpatient and Inpatient). They are responsible for facilitating improved overall quality, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff. Responsibilities Clinical Documentation Improvement Specialists (CDIS) review documentation in the medical record and information in an inpatient Patient Treatment File (PTF) and in outpatient encounters and facilitate modifications to the health record to identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity and accurately address all acute and chronic conditions. Other Duties and Functions include but are not limited to: Serve as a technical expert in health record content and documentation requirements. Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. Review appropriateness of and responses to queries through the review of query reports. Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting and to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of inpatient records with an emphasis on improving documentation while the patient is still in-house while Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective review of outpatient encounters. Provides education to the providers on documentation improvement in the health record to include the impact of documentation on coding, quality measures and reimbursement. Reviews 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 Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the facility. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Queries providers for clarification of conflicting or ambiguous documentation. Identifies trends and opportunities to improve documentation. Uses a variety of computer applications in daily activities and duties, such as Outlook, Excel, Word, and Power Point and is competent in the use of the health record applications VistA and CPRS as well as the Solventum encoder product suite and WebVIRR suite of products for PTF completion, Encounter Completion and Compliance E-mail Tracking. Work Schedule: 7:30 am -4:00 pm; Monday through Friday Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 70210F Requirements Conditions of Employment Complete all application requirements detailed in the "Required Documents" section of this announcement 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 dentification 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. 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. 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 Citizenship. Must be a United States Citizen per VA policy. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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: 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. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS Note. This position is above Full Performance/Journey Level and mastery level certification is required for all positions above the journey level. 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. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees may be reassigned, promoted up to and including the journey level, or changed to lower grade within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. Such employees in an occupation that requires a certification only at higher grade levels must meet the certification requirement before they can be promoted to the higher-grade levels. GRADE REQUIREMENTS Medical Records Technician (CDIS-Outpatient and Inpatient), GS-9 Experience. 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 RN, M.D., or DO, and one year of experience in clinical documentation improvement. Certification. Applicants at this level must posses either (1) a Mastery Level Certification by AHIMA or AAPC or, (2) a Clinical Documentation Improvement Certification by AHIMA or ACDIS. AHIMA/AAPC-Accepted Mastery Level Certifications: 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). AHIMA/ACDIS-Accepted Clinical Documentation Improvement Certifications: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist (CCDS) . 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 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. Reference. For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. This position is above full performance level. The grade at which an applicant may be selected for this vacancy is GS-9. Physical Requirements. The physical demands of the work require use of fingers; moderate walking and standing; near vision correctable at 13" to 16" to Jaeger 1 to 4; far vision correctable in one eye to 20/20 and to 20/40 in the other; hearing aid permitted; clear speech; emotional stability; moderate duty. 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 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.