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

🌍 Remote, USA 🎯 Full-time 🕐 Posted Recently

Job Description

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

DEPARTMENT OF VETERANS AFFAIRS
Veterans Health Administration
Bruce W. Carter VA Medical Center, Miami, FL

Location: Anywhere in the U.S. (remote job)
Work Schedule: Monday through Friday, 8:00 am to 4:30 pm
Salary: $65,735 to - $85,460 per year
Pay scale & grade: GS 9
Announcement number: CBTC-12889068-26-TAB
Control number: 857640200
Permanent Change of Station (PCS): Not Authorized
Telework: 100% remote work is authorized for this position, however it is only temporary until final changes are made to Return to Office

Summary
The Medical Records Technician - Clinical Documentation Improvement Specialist - Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

Assisting facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.
Collaboratively working with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided.
Compiling, reviewing, abstracting, analyzing and interpreting medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Reviews the health record and discusses the case with the clinical staff. Performs admissions reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record. Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption.
Other duties as assigned.

You must be a U.S. Citizen to apply for this job.
All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
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.
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.
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.

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.

United States Citizenship.
English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English.
Experience and Education:
Experience: One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the health records structure; OR
Education: An associate's degree from an accredited college or university with a major in health information technology/health information management, or a related degree with minimum 12 semester hours in health information technology/health information management; OR
Completion of an AHIMA approved coding program (or similar) leading to eligibility for coding certification; OR
Experience/Education Combination as defined in the announcement.
Certification: Must have Apprentice/Associate Level Certification through AHIMA or AAPC, or Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
Loss of Credential: Credentials must be maintained; failure to maintain may result in removal from the occupation.
May qualify based on Grandfathering provisions for current VHA employees.

Experience: One year of creditable experience equivalent to the journey grade level of MRT (Coder-Outpatient and Inpatient); OR an associate's degree or higher with three years of experience in clinical documentation improvement; OR Mastery level certification with two years of experience in clinical documentation improvement; OR clinical experience such as RN, M.D., or DO with one year in clinical documentation improvement.
Certification: Mastery level or clinical documentation improvement certification.
Knowledge, Skills and Abilities (KSA):
Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
Knowledge of anatomy/physiology, pathophysiology, pharmacology to interpret health records.
Ability to collect and analyze data and present results.
Ability to communicate with providers.
Knowledge of healthcare documentation regulations (The Joint Commission, CMS, VA).
Extensive knowledge of ICDCM/PCS, CPT, HCPCS; CC/MCC, MS-DRG, POA indicators.
Knowledge of severity of illness, risk of mortality, and CPT E/M criteria.
Knowledge of training methods and teaching skills for staff development.

Education
Note: Degrees must be recognized by the U.S. Department of Education.

Receiving Service Credit for Earning Annual Leave: Eligible for credit toward annual leave accrual.
Opt-in to share resume with hiring managers is available.
This job opportunity may be used to fill additional vacancies.
This position is in the Excepted Service and does not confer competitive status.
VA agencies encourage persons with disabilities to apply.
If you cannot apply online, contact the Agency for alternate submission.

Resume
Transcript
Special Note for Applications: Use the link to download the standard Clinical Resume Document if needed
Other documents as applicable (Cover Letter, DD-214/Statement of Service, Disability Letter, License, Certification, Transcripts, etc.)

To apply, visit the USAJOBS posting and follow the application steps; contact information:
Takisha Butler
Email: [email protected]
Bruce W Carter Department of Veterans Affairs Medical Center
1201 Northwest 16th Street
Miami, FL 33125

Next steps
After submission, you will receive a confirmation by email. Applications will be reviewed for qualification and eligibility; referrals issued; finalists notified by email.

Required Documents (detailed) included above.

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