Clarification from the agency

This job announcement is open to current, permanent VA employees and other federal employees. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

Major Duties and Responsibilities:

• Responsible for reviewing the overall quality and completeness of clinical documentation.
• 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 proper code selection.
• Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care.
• 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.
• Adheres to accepted coding practices, guidelines and conventions to ensure ethical, accurate, and complete coding.
• Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate 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 VAMC.
• Assists 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.
• Reports incorrect documentation or codes in the electronic patient health 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 the health record applications (VistA and CPRS) as well as the encoder 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.
• 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.
• 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.
• Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
• The documentation specialist is a member of the healthcare team, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.
• Additional duties may be assigned as determined necessary for the service.

Total Rewards of a Allied Health Professional


Work Schedule: Monday - Friday; 8:00 a.m. - 4:30 p.m.
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: Not authorized
Virtual: This is not a virtual position.
Functional Statement #: 54280-A

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.
• Must pass pre-employment physical examination / evaluation.
• 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

Basic Requirements-

Experience and Education - (A transcript must be submitted with your application if you are basing all or part of your qualifications on 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 4 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: 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


GS 9 Grade Level Requirements


GS 9 Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient) *Above Full performance*

• Experience.
  • 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

OR

• Clinical experience such as RN, M.D., or DO, AND one year of experience in clinical documentation improvement

GS 9 Certification

• Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

GS-9 MRT (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) - Knowledge, Skills, and Abilities: In addition to the experience above, you must demonstrate the following KSAs:

• 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 ICD CM and PCS. They must also possess a 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, and complexity of care.
• 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 vacancy is being announced above the FPL at a GS-9.

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:

• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action

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 (VA)
• License
• Other (1)
• Other (2)
• Performance Appraisal
• Professional Certification
• Resume
• Separation Notice (RIF)
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript

Next steps