Medical Records Technician (CDIS)

Medical Records Technician (CDIS)

Department: Department of Veterans Affairs

Location(s): Anywhere in the U.S. (remote job), United States

Salary Range: $61111 - $79443 Per Year

Job Summary: This position is in the Health Information Management (HIM) section at the Phoenix VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers.

Major Duties:

• Duties may include, but are not limited to: CDISs must be able to perform all duties of a MRT (Coder-Outpatient and Inpatient). CDISs serve as the liaison between health information management and clinical staff. 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 services rendered to patients, appropriate workload is captured, and resources are properly allocated. Review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. Identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. Recommend changes and/or update medical center policy pertaining to clinical documentation improvement. 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 review of query reports. Review health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership. Obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. Monitor trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education. Responsible for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met. Provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. Apply applicable coding conventions and guidelines to identify the principal and secondary diagnoses and complete significant procedures to accurately reflect the patient's hospital course and DRG assignment in the inpatient setting. These are also applied to accurately reflect medical necessity and level of service or procedure performed in the outpatient setting. Work Schedule: Mon-Fri 8am-4:30pm Telework: Not available Virtual: Yes, This position is eligible but may be required to return to the office permanently at a later date. Functional Statement #: 00000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized

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. Education or Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient); 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 Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of experience in clinical documentation improvement. AND Certification: Must have either a mastery level certification or a Clinical Documentation Improvement certificate such as CCDS is preferred. 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). GS-09 Grade Determinations: Experience. One year of creditable experience equivalent to the journey grade level of a MRT (GS-08) (Coder-Outpatient and Inpatient); AND Certification: Employees must have a (CDI) Clinical Documentation Improvement certification such as CCDS is encouraged. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii. 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. iii. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels. iv. Ability to establish and maintain strong verbal and written communication with providers. v. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines. vi. 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. vii. 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. viii.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/. Physical Requirements: The majority of work will be sedentary, but standing, bending may be necessary. 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).

How to Apply: All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 11/17/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12829121. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.

Application Deadline: 2025-11-17