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Medical Records Technician-Clinical Documentation Improvement Specialist (CDIS) - Inpatient
Veterans Health Administration · Posted 46 days ago
Remote United States $64K – $84K Apply by Aug 10, 2026 Medical Records Technician ESFJESTJISFJISTJ HealthcareTrades
Apply for this job → About the Role
The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician-Clinical Documentation Improvement Specialist (CDIS) - Inpatient. This position will serve within the Health Information Management Section under Patient Care Administrative Service. The incumbent must possess a mastery-level certification from AHIMA or AAPC, or a clinical documentation improvement certification approved by AHIMA or ACDIS.
What You'll Do
- →The 2-page Resume requirement does not apply to this occupational series.
- →For more information, refer to Required Documents below.
- →The Medical Records Technician-Clinical Documentation Improvement Specialist (CDIS)-Inpatient duties include, but are not limited to: Responsible for reviewing the overall quality and completeness of clinical documentation.
- →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.
- →Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
- →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.
- →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.
- →Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →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.
- →Total Rewards of a Allied Health Professional Work Schedule: Monday-Friday; 8:00am-4:30pm Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases.
- →When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).
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 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.
- ✓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.
- ✓Note: Only education or degrees recognized by the U.S.
Personality Fit
Job ID: 8b1c02d4-a772-4092-a18f-3ab4dc3e9e98
Posted via USAJobs