Job Listing
Medical Records Technician (Clinical Documentation Improvement Specialist-Inpatient/Outpatient)
Veterans Health Administration · Posted 5 days ago
On-site Tuscaloosa, AL $62K – $81K Apply by Sep 18, 2026 Medical Records Technician ESFJESTJISFJISTJ OperationsHealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) Section at the Tuscaloosa VA Medical Center and serves as a key member of the Medical Records Technician (MRT) team specializing in Clinical Documentation Improvement (CDI). The Clinical Documentation Improvement Specialist plays a critical role in ensuring the accuracy, completeness, and integrity of the health record, directly supporting patient care, healthcare operations, compliance, and resource allocation.
What You'll Do
- →Major duties include but are not limited to: Reviews inpatient and outpatient clinical documentation to ensure accuracy, completeness, and support of correct code assignment, severity of illness, and resource utilization.- Conducts concurrent and retrospective documentation reviews; identifies opportunities for clarification and improvement.
- →Serves as a liaison between HIM and clinical providers, facilitating communication to improve documentation quality and compliance Queries clinicians to clarify ambiguous, incomplete, or conflicting documentation; evaluates responses for accuracy and compliance with coding and documentation standards.
- →Provides focused education to providers on documentation requirements, E/M coding, CPT/ICD-10 specificity, and the impact of documentation on workload, quality measures, VERA, and reimbursement.
- →Assists in developing, updating, and implementing policies and guidelines related to clinical documentation improvement.
- →Reviews admissions, DRGs, treatment plans, lab results, and diagnostic data to verify documentation reflects patient acuity and clinical conditions.
- →Participates in interdisciplinary rounds to offer guidance on documentation, coding rules, DRG methodology, and reimbursement considerations.
- →Monitors trends or changes in industry standards, regulations, and coding guidance; identifies training needs and coordinates education with HIMS leadership and other stakeholders.
- →Collaborates with Provider Auditor and HIMS leadership to ensure accurate provider documentation and compliance with regulatory and accreditation requirements.
- →Maintains documentation review statistics, prepares summary reports, and analyzes data to identify trends, measure program effectiveness, and support leadership decision-making.
- →Ensures provider documentation aligns with national guidelines, VA policy, UHDDS definitions, and ethical coding practices.
- →Supports internal audits, compliance reviews, and process-improvement initiatives related to documentation, coding accuracy, and billing integrity.
- →Provides technical expertise and guidance on health record documentation issues, including patient confidentiality, informed consent documentation, legal requirements, and record content standards.
- →Contributes to staff training, orientation of new clinical providers, and intra-departmental education programs to strengthen documentation accuracy and quality.
- →Performs other duties as assigned.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓To be considered for this position, you must complete all required steps in the process.
- ✓In addition to the application and questionnaire, this position requires an online assessment.
- ✓The online assessment measures critical general competencies required to perform the 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 identification 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.
Personality Fit
Job ID: 5b462974-d738-4e42-a4fd-9b25d6d63450
Posted via USAJobs