Clarification from the agency

Area of Consideration (AOC): 1st AOC - Employees of Orlando VA Medical Center, including satellite locations. 2nd AOC - Department of Veteran Affairs Employees. 3rd AOC - Status Eligible (Transfers, Reinstatements, VEOA, Certain Military Spouses, etc.), VRA, 30% Disabled Veterans, Individuals with Disabilities. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

Duties and responsibilities include, but are not limited to:

• Responsible for providing outstanding customer service while processing incoming requests to the facility for release of information. Medical information requests are received in person, written, facsimile (fax) for the release of information from medical and administrative records pertaining to inpatients, outpatients and former patients
• Interview Veterans and/or family members to assist them in completing the required consent to release or obtain health information. He/she advises requestors of legal requirements and limitations of patient access to personal records. Determines the validity of consents for release off information, ensuring that a proper consent is obtained before release is made. Advises patients and other requestors of requirements and limitations of patient access to personal records. Incumbent enters request received, utilizing Document Storage System ROI Plus. (DSS ROI Plus) computer software for documenting and tracking requests received.
• Determines which information is to be released in compliance with existing laws (Privacy Act of 1974, Freedom of Information Act, and Health Insurance Portability and Accountability Act). Ensures that proper authorization exist before release is made.
• Receives and directs callers and visitors. Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services. Provides advisory and technical assistance to patients, administrative staff and professional staff regarding release of information. Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail.
• Employee composes responses to routine requests, such as first party requests, for release of patient information. Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters. Ensures the information released is limited to what is specifically authorized and to the person or agency designated to receive it.

Work Schedule: Monday - Friday, 7:30am to 4:00pm
Recruitment Incentive (Sign-on Bonus): Not Authorized
Permanent Change of Station (Relocation Assistance): Not Authorized
Pay: Competitive salary and regular salary increases
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 VA.
Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Telework: Yes - as determined by the agency policy.
Virtual: This is not a virtual position.
Functional Statement #: 82554F
Permanent Change of Station (PCS): Not Authorized

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.
• 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

Employees at this level must have either a Mastery Level Certification or a Clinical Documentation Improvement Certification.

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
  • (1) 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,
  • (2) 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,
  • (3) 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:
    • (a) 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.
    • (b) 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:
  • (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
  • (2) Mastery Level Certification through AHIMA or AAPC.
  • (3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
  • NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.
• English Language Proficiency. Medical Records Technician (CDIS Inpatient) appointed to direct patient-care positions must be proficient in spoken and written English as required by 38 U.S.C. 7403(f).

Grade Determinations:
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-9

• Experience.
  • One year of creditable experience equivalent to the journey grade level 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; NOTE: See basic requirements for a detailed definition of mastery level certification. OR,
  • Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.
• Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. NOTE: See basic requirements certification above for a detailed definition of mastery level certification and clinical documentation improvement certification.
• Assignment:
  • Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements.
  • Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
  • Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary.
  • Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements.
  • Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.
• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
  1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
  2. 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.
  3. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
  4. Ability to establish and maintain strong verbal and written communication with providers.
  5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
  6. 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.
  7. 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.
  8. 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/.

The full performance level of this vacancy is GS-9.

Physical Requirements: Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices.

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

To apply for this position, you must provide a complete Application Package which includes:

• Mastery level certification through AHIMA or AAPC or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Resume

Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.

Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.


The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

• Cover Letter
• DD-214/ Statement of Service
• Disability Letter (Schedule A)
• Disability Letter (VA)
• License
• Mastery level certification through AHIMA or AAPC or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• Resume/CV to include longer than 2-pages - See JOB ANNOUNCEMENT- Required Documents Box.
• Professional Certification
• Proof of Marriage Status
• Resume
• Separation Notice (RIF)
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.

Veterans' preference does not apply for internal or other current permanent Federal agency employees.

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