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Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient))
Veterans Health Administration · Posted 2 days ago
RemoteUnited States$62K – $80KApply by May 28, 2026Medical Records TechnicianESFJESTJISFJISTJHealthcareTrades
Apply for this job →About the Role
This position is in the Health Information Management Service (HIMS) at James J. Peters VA Medical Center. The incumbent is responsible for reviewing the overall quality and completeness of clinical documentation.
What You'll Do
- →Temporarily eligible for Remote work within 50 miles of a VA Medical Center.
- →May fall under the Presidential Memorandum tiled "Return to In-Person Work" which will require you to go into the office if the exemption is not approved at the next review.
- →Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)), GS-9 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 22 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.
Requirements
- ✓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.
- ✓Transcripts are not required but should be included with application materials if basing any of your qualifications on education.
Personality Fit
Job ID: 3f3909a6-87f3-4010-8753-75438df626c4
Posted via USAJobs