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Veterans Affairs, Veterans Health Administration Medical Records Technician (CDI) in Birmingham, Alabama


This position is located in the Business Management Service- Clinical Documentation Improvement (CDI) section at the Birmingham VA Medical Center, Birmingham Alabama. Medical Record Technician- Clinical Documentation Improvement Specialists (MRT-CDIS) are responsible for providing expertise and improved overall, quality, education, and completeness and accuracy of medical record documentation.


This is an OPEN CONTINUOUS ANNOUNCEMENT and will remain open until June 30, 2021. The initial cut-off date for referral of eligible applications will be 12 April 2021. Eligible applications received after that date will be referred at regular intervals, every Monday, or as additional vacancies occur on an as-needed basis until positions are filled. Medical Records Technician (CDIS) major duties include but are not limited to the following: Serve as technical expert in health record content and documentation requirements. Ensure accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis. Perform 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. Accountable for utilizing a variety of collaborative strategies with physicians, mid-level providers and other members of the interdisciplinary team, Medical Care Cost Recovery (MCCR) and Health Information Management Section. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data. Apply comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medication procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Conducts reviews of both inpatient and outpatient documentation to identify those with potential, documentation improvement opportunities, through periodic evaluation during the patient's stay or visit. Search the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Adhere to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary. Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS). Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided. Develop and implement ICD-10 CM/PCS training/education programs for all providers to ensure the CDIS program objectives are met. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance. Work Schedule: Monday - Friday 0730-1600

Financial Disclosure Report: Not required


Conditions of Employment


For the GS-9 MRT (CDIS) -

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

NOTE: See paragraph 2g above 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.

(b) Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification. NOTE: See paragraph 2g and 2h for a detailed definition of mastery level certification and clinical documentation improvement certification.

(c) Assignment. For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Inpatient CDISs must be able to perform all duties of a MRT (Coder-Inpatient). CDISs serve as the liaison between health information management and clinical staff. They are 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. They 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. They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity. They recommend changes and/or update medical center policy pertaining to clinical documentation improvement. They serve as a technical expert in health record content and documentation requirements. They query clinical staff to clarify ambiguous, conflicting, or incomplete documentation. They review appropriateness of and responses to queries through review of query reports. They perform reviews of the health record documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating orally and/or in writing to appropriate groups and leadership. They obtain appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable. They adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements. They 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. They are 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. They provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. They 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

(d) 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 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. References: VA Handbook 5005/122, Part II Appendix G57. The full performance level of this vacancy is GS-09. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-9. Preferred Experience: 3-5 years of outpatient and inpatient coding experience.


IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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: 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:

Additional Information

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. VA may offer newly-appointed Federal employee's credit for their job-related non-federal experience or active duty uniformed military service. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. Special Employment Consideration: VA encourages persons with disabilities to apply, including those eligible for hiring under 5 CFR 213.3102(u), Schedule A, Appointment of persons with disabilities (i.e., intellectual disabilities, severe physical disabilities, or psychiatric disabilities), and/or disabled veterans with a compensable service-connected disability of 30% or more. For more information on how to apply using this appointment authority via the Selective Placement Coordinator within the office, contact the facility Human Resources Department at (205) 933-8101.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. The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced Federal competitive service employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit appropriate documentation and be found well-qualified (have a final rating of 85 or more before any Veterans preference points) for this vacancy. Information about ICTAP and CTAP eligibility is on OPM's Career Transition Resources website at job opportunity announcement may be used to fill additional vacancies. If you are unable to apply online view the following link for information regarding an Alternate Application.