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Medical Records Technician (Clinical Documentation Improvement Specialist-Inpatient)
Veterans Health Administration · Posted 13 days ago
Hybrid Richmond, VA $64K – $84K Apply by Sep 11, 2026 Medical Records Technician ISFJISTJ HealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management Section (HIMS) at the Central Virginia VA Health Care System (CVHCS) in Richmond, Virginia. The Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Inpatient ) MRTs (Coder) is skilled in classifying medical data from patient health records.
What You'll Do
- →As a Medical Records Technician ( Clinical Documentation Improvement Specialist ( CDIS- Inpatient), you will be responsible for classifying medical data from patient health records in the hospital.
- →You will be responsible for analyzing and abstracting patients' health record documentation and assigning alpha-numeric codes for each diagnosis and procedure.
- →You must possess expertise in ICD, CPT, and HCPCS code assignments.
- →CDISs serve as the liaison between Health Information Management and clinical staff.
- →Facilitates 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.
- →Identifies 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.
- →Queries clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
- →Reviews appropriateness of and responses to queries through review of query reports.
- →Responsible for reviewing the overall quality and completeness of clinical documentation.
- →Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house.
- →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 including admissions and discharges, surgical cases, observation and professional services provided in the emergency department.
- →Develops criteria, collects data, analyzes and graphs results, creates reports, and communicates orally and/or in writing to appropriate groups and leadership.
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.
- ✓Must pass pre-employment physical examination.
- ✓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.
Personality Fit
Job ID: ce8da418-0547-4cfa-a240-a7199098d8cb
Posted via USAJobs