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Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS)
Veterans Health Administration · Posted 6 days ago
Hybrid Miami, FL $66K – $85K Apply by Sep 23, 2026 Medical Records Technician ISFJISTJ HealthcareTrades
Apply for this job → About the Role
The Medical Records Technician - Clinical Documentation Improvement Specialist - Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).
What You'll Do
- →Recruitment Incentive (Sign-on Bonus):Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases.
- →Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
- →Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
- →Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
- →Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Remote:100% remote, pending exemption to RTO EO Telework: Maybe Authorized Virtual: This is not a virtual position.
- →Ensures provider documentation is complete and supports the diagnoses and procedures coded.
- →Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- →Reports incorrect documentation or codes in the electronic patient health record.
- →Collaboratively working with the professional clinical staff and provides support and education on documentation issues.
- →Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported.
- →Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided.
- →Compiling, reviewing, abstracting, analyzing and interpreting medical data incidental to a variety of patient care and treatment activities.
- →Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay.
- →Reviews the health record and discusses the case with the clinical staff.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
- ✓Applicants who refuse to be tested will be denied employment with VA.
- ✓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.
Personality Fit
Job ID: f744e3ab-00d8-424f-b56f-5676e745afca
Posted via USAJobs